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Discrimination Complaint Form

2. Complete this form to file a complaint of discrimination at any place of public accommodation located in Orange County, or to file a complaint of discrimination with respect to an Orange County Government program or activity. There is no cost to file a complaint. <br> <br> Your discrimination complaint will be reviewed by a specialist to determine if it alleges acts that might violate Article VI of the Orange County Civil Rights Ordinance; 40 C.F.R. Part 5 and 7; Title VI of the Civil Rights Act of 1964, as amended; section 504 of the Rehabiliation Act of 1973, as amended; the Age Discrimination Act of 1975, as amended. The specialist will contact you for any additional information needed to complete this review. If your complaint involves a possible violation of one of the above laws, the specialist will assist you in filing an official complaint.

   Complete this form to file a complaint of discrimination at any place of public accommodation located in Orange County, or to file a complaint of discrimination with respect to an Orange County Government program or activity. There is no cost to file a complaint.
   
   Your discrimination complaint will be reviewed by a specialist to determine if it alleges acts that might violate Article VI of the Orange County Civil Rights Ordinance; 40 C.F.R. Part 5 and 7; Title VI of the Civil Rights Act of 1964, as amended; section 504 of the Rehabiliation Act of 1973, as amended; the Age Discrimination Act of 1975, as amended. The specialist will contact you for any additional information needed to complete this review. If your complaint involves a possible violation of one of the above laws, the specialist will assist you in filing an official complaint.

4. Enter Your Personal Information

6. First Name*

7. Last Name*

9. Address*

10. Email Address

12. City*

13. State*

14. Zip Code*

16. Daytime Phone Number

17. Evening Phone Number

18. Best Time to Call
    -- Select One --DayEvening

20. Who else can we call if we cannot reach you?
    Contact Number 1

    Contact Number 1

22. First Name*

23. Last Name*

24. Organization

26. Daytime Phone Number*

27. Evening Phone Number

28. Best Time to Call
    -- Select One --DayEvening

30. Contact Number 2

    Contact Number 2

32. First Name

33. Last Name

34. Organization

36. Daytime Phone Number

37. Evening Phone Number

38. Best Time to Call
    -- Select One --DayEvening

40. Enter Complaint Information

42. What happened to you?*

    Provide a specific and detailed description of the decision(s) or actions(s) including the date (or date range) which is alleged to have constituted unlawful discrimination in violation of Article VI of the Orange County Civil Rights Ordinance; 40 C.F.R. Part 5 and 7; Title VI of the Civil Rights Act of 1964, as amended; section 504 of the Rehabiliation Act of 1973, as amended; the Age Discrimination Act of 1975, as amended. Describe the harm alleged to have occurred, or which will occur, because of alleged discrimination. (4000 character limit)

44. Why do you believe you are being discriminated against?

    -Age (over 40)
    -Color
    -Disability
    -Familial status (families with children under 18)
    -National origin
    -Religion
    -Race
    -Sex
    -Veteran status
    
    Briefly explain why you think your rights were denied because of any the factors listed above. (4000 character limit)

46. Who do you believe discriminated against you?
    Identify the parties alleged to be subjected to, or potentially impacted by the alleged discrimination.

    Identify the parties alleged to be subjected to, or potentially impacted by the alleged discrimination.

48. First Name

49. Last Name

51. Organization

52. Address

54. Where did the alleged act of discrimination occur?
    Provide the address.

    Provide the address.

56. Address

57. City*

59. State*

60. Zip Code

62. When did the last act of discrimination occur?*
    When did the last act of discrimination occur?

63. Is the alleged discrimination continuous/on-going?

    1. Yes
    2. No

Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field