Discrimination Complaint Form

PERSONAL INFORMATION
Full Legal Name (required)

Street Address (required)

City, ZIP

Preferred Phone Number

Email Address (required)

My complaint of discrimination is based on my (check all that apply) (required)
RaceColorReligionSexMilitary or Veteran StatusNational OriginAgeAncestryFamily StatusDisabilitySexual OrientationGender IdentityGender ExpressionReprisalOther (Describe in Details)

Information regarding who you are filing a complaint against
Name (required)

Address

Phone Number (if known)

Email Address (if known)

Date(s) you believe you were discriminated against, and approximate time. (required)

Upper Arlington address where you believe you were discriminated against. (required)

COMPLAINT DETAILS
Tell us more about each act of discrimination that you have experienced. Please include dates, names of people involved, and explain why you think it was discriminatory.

If any, what reason were you given for this action? When was this reason given to you and by whom?

I HEREBY CERTIFY THE FOLLOWING

Please initial each line

This complaint has been submitted to the Clerk of Council within 180 days following the most recent unlawful discriminatory act alleged in the complaint. (required)

The incident location provided in the complaint is within the City of Upper Arlington, Ohio. (required)

The complaint includes all the information required by C.O. §525.02(K). (required)

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.

Full Name (required)

By checking this box, I swear or affirm under penalty of perjury that the information I have provided in this complaint is accurate, to the best of my knowledge.