Civil Rights Intake Questionnaire

Your Information

Party or Firm You Are Complaining Against

Complaint Information

Please provide a short summary of your discrimination complaint below

Is the alleged discrimination ongoing?

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

Do you have an attorney

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

Is any legal action pending?

List any other agencies contacted regarding your complaint

Additional 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 questionnaire is true and accurate.

Thank you for taking the time to complete this questionnaire.

You will be contacted to schedule an intake interview with this office.