Township of Union Complaint Form. Note: The following information is needed to assist in processing your complaint.
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1 Township of Union Complaint Form Note: The following information is needed to assist in processing your complaint. A. Complainant s information: Name: Address: City/State/Zip Code: Telephone Number (Home): Address: Accessible Format Requirements? (Select One or More) o Large Print o TDD o Audio Tape o Other B. Person discriminated against (if someone other than complainant): Name: Address: City/State/Zip Code: Telephone Number (Home): Address: Relationship to the person for whom you are complaining: Please explain why you have filed for a third party: _ Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. o Yes o No C. Which of the following best describes the reason you believe the discrimination took place? Race Color National Origin Other: D. On what date(s) did the alleged discrimination take place?
2 Other: E. Please describe the alleged discrimination. Explain what happened and whom you believe was responsible. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If additional space is needed, add a sheet of paper. F. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? List all that apply. Federal Agency Federal Court State Agency State Court Local Agency If you have checked above, please provide information about a contact person at the agency/court where the complaint was filed. Name: Title: Address: City/State/Zip Code: Telephone Number (Home): Address: G. Please sign below. You may attach any written materials or other information that you think is relevant to your complaint. Signature Attachments: Yes No Date H. Submit form and any additional information to: Township of Union Legal Department 1976 Morris Avenue Union, NJ 07083
3 Nota: La siguiente información es necesaria para ayudarle a procesar su queja. A. Información del reclamante: Nombre: Dirección: Número de teléfono (domicilio): Requisitos de formato accesible? (Seleccione uno o más) O Impresión grande O TDD O Cinta de audio O Otro B. Persona discriminada (si alguien que no es el demandante): Nombre: Dirección: Número de teléfono (casa): Relación con la persona por la que se queja: Explique por qué ha presentado un tercero: Por favor confirme que usted ha obtenido el permiso de la parte agraviada si usted está archivando en nombre de Una tercera parte. Oh si O no C. Cuál de las siguientes opciones describe mejor la razón por la que cree que ocurrió la discriminación? Race Color National Origin Otro:
4 D. En qué fecha (s) tuvo lugar la supuesta discriminación? Otro: E. Describa la supuesta discriminación. Explica lo que pasó y quién crees que fue responsable. Describa a todas las personas involucradas. Incluya el nombre y la información de contacto del Persona (s) que discriminó (si se conoce), así como nombres e información de contacto de cualquier persona testigos. Si necesita espacio adicional, agregue una hoja de papel. F. Ha presentado esta queja ante cualquier otra agencia federal, estatal o local, o con Tribunal estatal Enumere todas las que apliquen. Agencia Federal Corte federal Agencia del estado Tribunal estatal Agencia Local Si ha comprobado anteriormente, proporcione información sobre una persona de contacto en la agencia / tribunal donde La queja fue archivada. Nombre: Título: Dirección:
5 Número de teléfono (domicilio): G. Por favor firme abajo. Usted puede adjuntar cualquier material escrito u otra información que considere pertinente A su reclamación. Fecha de firma Adjuntos: Sí No H. Envíe el formulario y cualquier información adicional a: Township of Union - Departamento Jurídico 1976 Morris Avenue Union, NJ
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