Now more than ever before

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MOVING POWERFULLY FORWARD

IOWA-NEBRASKA NAACP COMPLAINT FORM

***IMPORTANT: PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS FORM

OUR MISSION

Our mission is to achieve equity, political rights, and social inclusion by advancing policies and practices that expand human and civil rights, eliminate discrimination, and accelerate the well-being, education, and economic security of Black people and all persons of color.

VISION STATEMENT

We envision an inclusive community rooted in liberation where all persons can exercise their civil and human rights without discrimination.

PURPOSE OF COMPLAINT FORM

Please be advised that filing a complaint of discrimination with the NAACP is considered a request for support and does not guarantee that the NAACP will represent you in any matter, legal or otherwise. The filing of a this form does not form an attorney-client relationship. The NAACP may not give legal advice to any persons or entity, but upon investigating a matter, may refer any person or entity seeking legal advice to attorneys who are available to receive such referrals.

REFERRAL STATEMENT

The NAACP Iowa-Nebraska State Area Conference of Branches will seek to refer complaints to the appropriate local unit or agency for processing. In some cases which merit state level involvement, the NAACP Iowa-Nebraska retains the option to process the complaint directly or in concert with a local unit/branch.

ADDITIONAL TIME-SENSITIVE INFORMATION:

If you believe that you have a discrimination claim, we strongly recommend that you also file a claim with the appropriate local, state or federal agency as soon as possible. Failure to do so may limit the opportunity to rectify the issue. Filing time limits can be as short as 90 to 300 days. Please find a list of some agencies here.

SPEAK TO A LAWYER: NAACP & ISBA FREE CIVIL RIGHTS CLINIC

The NAACP Iowa-Nebraska State Area Conference and the Iowa State Bar Association Civil Rights & Public Interest Law Section are partnering to provide free legal consultations to help protect your rights. If you are interested in speaking with an attorney at our Free Civil Right Clinic, please check yes at the end of this form. Only completed forms will be considered. Please note that completing the form does not automatically mean you will be able to speak with an attorney. If you are selected, we will contact you prior to the clinic to schedule your time. Click here for the clinic flyer. The clinic convenes monthly at the Iowa State Bar Association and via zoom to ensure statewide access.

Today's Date

Month

Day

Year

First name

Last name

Home Phone

Cell Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date of Incident or Situation

Month

Day

Year

Additional dates of Incidents or situation? Please use a full calendar date.

Are you a member of the NAACP?

Yes

Which of the following NAACP branches / chapters are closest to you?

Is this a complaint about discrimination?

Yes

What was the basis of the discrimination?

Race, Culture, Ethnicity or Color

Other

If you answered "Other" above, please specify the type of complaint.

Who or what entity do you believe discriminated against you?

Please provide the contact person(s) for the discriminating party. (Include name, title, complete address, email and phone number.)

Please describe what happened in chronological order, being as detailed as possible.

Location where the incident happened?: List complete addresses.

What effect has the incident(s) had on you?

Do you have an attorney?

Yes

Have you filed a lawsuit or taken legal action?

Yes

If you have an attorney, what is the name, phone number, and address of your attorney?

If you have taken legal action, what is the outcome or current status of any action taken?

Have you filed a complaint with another agency/entity?

Yes

If so, please indicate which of the following agencies you have filed a complaint with?

The discriminating entity's leadership or complaint process

Equal Employment Opportunity Commission (EEOC)

Department of Justice (DOJ)

Department of Civil Rights

Community Leader or Organization

Other

If so, what is the outcome or status of complaints filed with other agencies/entities?

Please upload any documentation or files relevant to your complaint.

File upload

What is your desired outcome? Be as detailed as possible.

If you do not have an attorney, would you like to speak to an attorney at our Free Civil Rights Clinic? ***Please note, clicking "Yes" does not guarantee that you will be able to speak with an attorney.

Yes

All cases are screened and if you are chosen for the clinic we will contact you and schedule your time. Only completed forms will be considered. The clinic convenes monthly at the Iowa State Bar Association and via zoom to ensure statewide access.

RELEASE OF LIABILITY

I affirm that the statements that I have made above are accurate to the best of my knowledge and belief. I hereby request the assistance of the of the Iowa-Nebraska State Area Conference of Branches and/or its appropriate units in seeking a remedy to the situation described above. I hereby authorize the officials of the NAACP to have access to information and documents which are relevant to my claim of discrimination described above.

I have read this form in it's entirety and I understand that by signing this document in the space below, I hold the NAACP harmless for any and all damages, legal claims or lawsuit arising from involvement.

I do understand and affirm.

Please sign this form here. Signature

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Please confirm your signature but providing the last 4 digits of your social security number.