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DISCRIMINATION COMPLAINT FORM

PURPOSE: The purpose of this form is to assist you in filing a discrimination complaint under the Upper Arlington Anti-Discrimination Ordinance. You are encouraged, but not required, to use this form to file your complaint. If you instead choose to write a letter, it must contain all of the information requested in this form and be signed by you or your authorized representative.

This form can be filled out and submitted online below. You may also send your PDF complaint form by e-mail to [email protected], you can mail it to: Attn: City Clerk, 3600 Tremont Road, Upper Arlington, OH 43221 or place it in the City’s drop box, located in the Kenny Road parking lot of the Municipal Services Center, 3600 Tremont Road.

Please note, if your complaint contains all the required information, the first step in the process is a referral to mediation.

    PERSONAL INFORMATION






    RaceColorReligionSexMilitary or Veteran StatusNational OriginAgeAncestryFamily StatusDisabilitySexual OrientationGender IdentityGender ExpressionReprisalOther (Describe in Details)


    Information regarding who you are filing a complaint against







    COMPLAINT DETAILS


    I HEREBY CERTIFY THE FOLLOWING

    Please initial each line




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


    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.

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