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Crowley County DHS Civil Rights Complaint Form
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Client/Complainant Information (Please type or print clearly)
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Client Name
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Client Residential Address
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Client Mailing Address (if different from residential address)
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Client Telephone Number & email address
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Information about discriminating agency and/or parties
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Agency name and/or person's name
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Information about discrimination (circle as many as apply)
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race, color, national origin, sex, creed, religion, political beliefs, age, disability, public assistance status,
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sexual orientation
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If you filed this charge with any other agency, please give the name, address and telephone number of
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the agency and the name of the investigator assigned to this case.
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Details of Discrimination
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Explain what happened to you, including the following points:
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1. Why you believe you were treated differently. 2. How you were treated differently from other people
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3. Give the date(s) of the incident(s).
4. Give the name(s) of the people who were directly involved.
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5. If there were any witnesses, give their name(s), contact information and explain what information
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they can provide. 6. What resolution do you seek? 7. Any additional information
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If you need more space, attach additional pages.
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Signature Date
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To be completed by investigating County Agency. Provide summary and any corrective action ordered
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For additional information or help in completing this form, please contact:
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Crowley County Department of Human Services Director
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719-267-3546 (voice) 719-267-5296 (fax) 711 or 1-800-659-2656 (TTY/TDD)
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