Form Center

2. City of Owatonna
4. Discrimination Complaint Form
6. Complainant*
7. Email Address
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Alternate Phone Number
18. Is the Complainant the same as the Person Discriminated Against?*
    -- Select One --YesNo
20. Person Discriminated Against Name
21. Person Discriminated Against Email Address
23. Person Discriminated Against Address
25. Person Discriminated Against City
26. Person Discriminated Against State
27. Person Discriminated Against Zip Code
29. Person Discriminated Against Phone Number
30. Person Discriminated Against Alternate Number
32. Government, or organization, or institution which you believe has discriminated:
34. Name*
35. Address*
37. City
38. County
39. State
40. Zip Code
42. Phone Number
44. When did the discrimination occur?*
    When did the discrimination occur?

    When did the discrimination occur?
46. Describe the acts of discrimination providing the name(s) where possible of the individuals who discriminated:*
48. Have efforts been made to resolve this complaint through the internal grievance procedure of the government, organization, or institution? *
    -- Select One --YesNo
50. If yes: what is the status of the grievance?
52. Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agency or court?*
    -- Select One --YesNo
54. Agency or Court
55. Contact Person
57. Agency's Address
59. Agency's City
60. Agency's State
61. Agency's Zip Code
63. Agency's Phone Number
64. Date Filed
    Date Filed
66. Do you intend to file with another agency or court? *
    -- Select One --YesNo
68. Agency or Court
69. Agency's Address
71. Agency's City
72. Agency's State
73. Agency's Zip Code
75. Agency's Phone Number
77. Additional Information
79. Submitted By:*
80. Submitted Date:*
    Submitted Date:

    Submitted Date:
Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit

* indicates a required field