State Seal

Terry Goddard
Arizona Attorney General

Civil Rights Complaint Form
(en español)
Press tab to go from field to field.  

  YOUR INFORMATION   PARTY OR FIRM YOU ARE
COMPLAINING AGAINST
Name: Name:
Address: *Address:
City: City:
County: State:
State: Zip:
Zip: Phone:
(if known)
Home Phone:
*e-mail address:
Work Phone:   * address or e-mail address of business required
Facsimile:    
E-Mail Address:    

Who else can we call, if we cannot reach you?

Contact's Name: Daytime Phone:
Best Time to Call: Evening Phone:

Please provide a short summary of your discrimination complaint below:

Date of last alleged act of discrimination:

Is the alleged discrimination ongoing?
Yes No

Please indicate all of the following categories that apply to your complaint against the person or business listed above:







Housing







Public Accommodations (Example: Restaurant, Store, Museum, Theatre)





Retaliation

Voting





Do you have an attorney?
Yes No

If yes, please provide the attorney's name and address:

Is any legal action pending?
Yes No

List any other agencies contacted regarding your complaint:

Comments:

Declaration: By submitting this form electronically, I declare, under penalty of perjury under the laws of the state of Arizona that the information in this complaint is true and accurate.

Name:

Date:

Thank you for taking the time to complete this form.

You will be contacted within approximately 24 hours to schedule an intake interview with this office.

Please print the following page for your records.