Contact Info:

Your Name:

Address:

City: State: Zip Code:

Home Phone: Work Phone:

Email Address:

Complaint info:

Victim's Name:

Date of Birth:   Relation to Victim:

Complaint Against (Company/Gov't Agency):

Complaint Against: (Individual Name/s):

Address:

City: State: Zip Code:

Phone: May we contact this person? Yes No

Nature of Complaint:

Description of the Complaint

Where did this incident occur? (city/county/state):

When did this incident occur? (Be specific):

Please describe the incident in as much detail as possible.

Witness to the Incident:

Name: Phone:

Name: Phone:

Name: Phone:

Questions:

Have you filed a complaint with another organization or agency?  Yes No

If so, what is the status of your complaint?

Have you consulted an attorney?  Yes  No

If so, please provide the following information about the attorney:

Name:

Address:

City: State:   Zip Code:

Phone:     Fax:

What action, if any, is the attorney taking?

May we contact the attorney?  Yes  No

Have you done anything on your own to address this problem?  Yes  No

If yes, describe your efforts:

What would you like the ACLU of Mississippi to do for you?

Are you willing to be a Plaintiff in Litigation?  Yes  No

Evidence/Supplementary Materials

If you send our office any documentation such as letters from government officials, relevant laws and policies, etc. via mail, DO NOT send the originals.  Send only copies; the ACLU of Mississippi cannot be responsible for returning documents.

I certify that I have read the information contained in this complaint and that all information I have given is accurate and complete to the best of my knowledge and belief.  I understand that by accepting this complaint, the ACLU of Mississippi is NOT representing me and that the ACLU is NOT responsible for meeting any deadlines or statute of limitation.  I hereby authorize the ACLU to use this information in any manner it deems necessary.

I agree to the above terms (required)

I disagree with the above terms