Forms • Henderson County, KY • CivicEngage

TYPE OF COMPLAINT:

	EMPLOYMENT
	HOUSING

	PUBLIC ACCOM
	OTHER

NAME (INDICATE MR., MS., MRS.)

TELEPHONE (Include area code)

NAMED OF THE PARTY WHO DISCRIMINATED AGAINST ME

COUNTY OF THE PARTY WHO DISCRIMINATED AGAINST ME

ADDRESS OF THE PARTY WHO DISCRIMINATED AGAINST ME

TELEPHONE WITH AREA CODE OF THE PARTY WHO DISCRIMINATED AGAINST ME

NUMBER OF EMPLOYEES / HOUSING UNITS OF THE PARTY WHO DISCRIMINATED AGAINST ME

CAUSE OF DISCRIMINATION BASED ON

PLEASE GIVE A DESCRIPTION OF OTHER IF IT WAS SELECTED

THE PARTICULARS ARE:

LAST DAY OF HARM: PLEASE INDICATE MONTH, DAY & YEAR

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. BY ENTERING YOUR NAME YOU ARE SIGNING THIS COMPLAINT*

DATE OF COMPLAINT: PLEASE PUT MONTH, DAY & YEAR
*

* indicates required fields.