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Complaint of Discrimination Form - 2022Complaint of Discrimination Form under City Code Title 2 Local Commission #________________ ICRC CP#________________ Office of Equity and Human Rights City of Iowa City 410 E. Washington Street Iowa City, Iowa 52240 Note: Please type or print 1. What is your name? _____________________________________________________________ 2. What are your pronouns? ________________________________________________________ 3. What is your street address? ______________________________________________________ City _________________________________________State ____________ Zip Code _________ 4. Telephone number: (_____) ____________ 5. What is your email address? ______________________________________________________ 6. What is your date of birth? ________________________________________ Sex: ___________ 7. Have you previously filed this complaint with any organization or agency?  Y  N If yes, who ____________________________________________________________________ 8. On what basis(es) do you feel you have been discriminated against? Please check all that may apply.  Age  Color  Gender Identity  Race  Creed  Religion  Marital Status  Sex  Disability  National Origin  Familial Status  Retaliation*  Sexual Orientation  Presence of Absence of Dependents  Public Assistance Source of Income *Because I filed prior complaint or opposed a discriminatory practice. 9. Please check the area in which the discrimination occurred.  Credit  Education  Housing  Employment  Public Accommodations 10. What is the Full Legal Name of the Business or Company that discriminated against you? ___________________________________________________________________________ 11. What is the company’s mailing address? City: __________________________ State: Iowa Zip Code: ____________ County: ________________________ Telephone Number: (_____) __________ 12. What is the name of the person who discriminated against you? _____________________________________________________________________________ 13. What does that business/company do? _____________________________________________________________________________ 14. If the company named in #10 is owned by another company, what is the Full Legal Name of the Owner Company? (Parent or Corporate Office of Company listed in #10.) _____________________________________________________________________________ 15. What is that company’s street address? City: _________________________ State: Iowa Zip Code: ____________ Telephone Number: (_____) __________ 16. Give approximate total number of full and part-time employees at all employer locations: _______________. 17. Identify the person at the company who discriminated against you? Name: __________________________________________________ Position/Title: ____________________________________________ 18. If you are claiming harassment, who harassed you? Name: _________________________________________________ Position/Title: ___________________________________________ 19. What is the last date that something discriminatory happened to you? _________________ 20. What happened on that date? Please fill in the particulars of your complaint below. Be sure to state why you feel you were discriminated against. Be sure to address each basis you checked on page 1. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ I certify under penalty of perjury and pursuant to the laws of the City of Iowa City, the State of Iowa and the laws of the United States of America that the preceding charge is true and correct. X __________________________________________________ Date _______________________ Signature of Complainant