Step 1 of 1

PLEASE READ COMPLETELY BEFORE FILLING OUT FORM. THIS COMPLETED PRELIMINARY INFORMATION DOES NOT CONSTITUTE A COMPLAINT.

A formal complaint may be completed at a later date.

THIS INTAKE SURVEY WILL ALLOW US TO DETERMINE IF WE CAN TAKE YOUR COMPLAINT - PLEASE COMPLETE IT TO THE BEST OF YOUR ABILITY. IF YOU NEED ASSISTANCE, CONTACT US.

NOTICE OF CONFIDENTIALITY


The information contained in this communication from the Office of the City of Muncie Human Rights Commission is privileged and confidential, and is intended for the sole use of the person or entities who are the addressees. If you are not an intended recipient of this communication, the dissemination, distribution, copying, or use of the information it contains is strictly prohibited. If you have received this communication in error, please immediately contact the Commission at (765)747-4854 to arrange for the return of this information. Thank you.

* Denotes a required field

Contact Information

*
*
Daytime Phone Number*
-- ext
 
*
If we are unable to contact you, the submitter, whom could we contact?
 
 
 
What is a phone number at which they can be reached? 
-- ext

Complaint Information

Type of Complaint*
Do you believe discrimination occurred due to your (select one from list)*
If discrimination occurred due to age list your birth date 
 , 
 
Phone number of Employer, Company, Landlord or other institution 
-- ext
 
 
Date Hired 
 , 
Most recent date of harm 
 ,