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Discrimination Complaint Form

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The purpose of this form is to assist you in filing a discrimination complaint with the Crime Victim Assistance Division in connection with one of its funded organizations or services. You can complete this form for yourself or on behalf of another person.

Submitter Information

Please fill out the first part of this form about you, the person submitting this form.

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Person(s) discriminated against, if different from above
Is this discrimination complaint about you:
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Agency and department or program that discriminated
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**Please note: The final report produced at the completion of the complaint investigation will become public record. All personally identifying information for the victim/survivor would be withheld and/or redacted per federal and state confidentiality requirements.

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