E-Gov Services City of Muncie

WARNING! Please do not use this form to report issues of an emergency nature or for conditions requiring an immediate response. If your issue is an emergency, please use the telephone and dial 911.

Human Rights Complaint Form

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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.

* Information is required.

Contact Information

* First Name:
* Last Name:
Email:
* Daytime Phone:	() –
* Address:
* City:
* State:
* ZIP:

When we are unable to contact you, whom could we contact?

What is your relationship to this person?

What is their address?

What is a phone number at which they may be reached?

Type of Complaint:

Employment
Housing

Education
Public Accommodation

Finance
Other

Do you believe discrimination occurred due to your (select one):

If discrimination occurred due to age, list your birth date (dd/mm/yyyy):

Name of Employer, Company, Landlord, or other institution:

Employer, Company, Landlord, or other Institution Phone Number:

Employer, Company, Landlord, or other Institution Address:

If this is an employment complaint, give approximate number of employees:

Date Hired (dd/mm/yyyy):

What is your most recent date of harm?

Are you now working with any other agency in trying to resolve your problem (Union or Workman's Comp)?

Check here to have email confirmation of this submission.

* Information is required.

Notes:

If you send us a message, you will receive a Tracking Number allowing you to follow-up with your request, at your convenience.

Internal Use Only, Leave Blank:
Please leave this field blank and remove any values that have been populated for it.