NATIONAL ASSOCIATION FOR THE ADVANCEMENT OF COLORED PEOPLE
COMPLAINT GUIDELINES
Please read each attached page carefully. Please complete this form, have it notarized and return to:
Mercer County Branch NAACP
700 Hamilton Avenue
Farrell, PA 16121
Phone: (724) 981-4140
Fax: (724) 981-1324
email:farrellnaacp@verizon.net
PLEASE NOTE:
• The NAACP cannot help you with your civil rights complaint until this form has been completed
and returned;
• Thorough completion of this form will help to expedite the handling of your complaint;
• The sheer volume of complaints received prevents the NAACP from pursuing every matter. Our
ability to assist is directly related to membership support. We do not receive financial support from
the government.
FILING A CIVIL RIGHTS COMPLAINT
To process a civil rights complaint, the individual must be able to provide enough information to
reasonably establish that there has been a violation of the law. To establish grounds, it will be helpful
to the investigating agency if you can provide the following information:
• The name, address and telephone number of the person or business against whom you are
complaining and, for employment complaints, your best estimate of the total number of persons
employed by the business;
• The dates of all alleged discriminatory incidents and the names of everyone involved;
• Specific examples of different/discriminatory treatment, indicating the people and conduct
involved;
• Names, addresses and telephone numbers (if possible) of all witnesses;
• Copies of any relevant policies and/or documents;
• For an employment complaint that involves a union, the name, address and telephone number of
the union local and the relevant representative, including the status of any filed grievance(s);
• Copies of any complaints filed with any state or federal agency.
INFORMATION TO CONSIDER WHEN
FILING A CIVIL RIGHTS COMPLAINT
• If it is an employment matter, it can still be referred to the Equal Opportunity Commission
(EEOC) if the alleged discriminatory act(s) occurred within the past 300 days;
• You should be able to provide a reason for your belief that the act(s) occurred because of religion,
race, color, national origin, age1
, sex, height2
, weight3
, marital status4
, familial status5
, physical or
mental disability, arrest record6
, or in retaliation for making or participating in a complaint about
one of these categories;
• The alleged discriminatory act(s) occurred in Santa Clara County;
• The person or entity against who you are complaining is not a United States, Canadian or Native
American governmental agency;
• The matter is not pending in any court of law
1 In education issues, age and marital status applies only to records made for admission purposes. 2 Height, weight and arrest record apply to employment only. 3 See Footnote #2, above. 4 See Footnote # 1, above. 5 Applies to housing only. 6 See Footnote #2, above.
NAACP COMPLAINT FORM
(Please PRINT or TYPE)
Dear ____________ Community Member:
San Jose/Silicon Valley Branch NAACP will refer complaints alleging employment discrimination to an
appropriate agency for official investigation, i.e., EEOC or Local Human Rights Commission and monitor the
agency’s work on all cases referred by the NAACP. Completing this form does not constitute filing an official
complaint with a legal authority.
To the extent resources allow, the San Jose/Silicon Valley Branch of the NAACP may provide other supportive
assistance to the complainant. In virtually all instances of employment discrimination, complainants will lose their
right to any form of legal remedy if they do not file a complaint with the EEOC within 180 days of the event of
the alleged discriminatory conduct and/or act. Please answer all questions and be as specific as possible. These
directions are numbered to match the questions.
Question 1: Be sure to give your full name and address. If you do not have a phone, give a phone number where
you can be reached.
Question 2: Please check the box that indicates what you believe to be the cause of discrimination (if other, please
state what other).
Question 3: If you believe that other parties (for example, a labor union or any employment agency, in addition to
an employer) were involved in the act of discrimination, list them on the last line of section 3.
Questions 4, 5 and 6: If you have consulted an attorney or filed this complaint with a state or local human relations
commission, Federal government, union or agency, check “yes” and give the name of the entity.
Question 7: Give the day, month and year of the most recent incident when discrimination took place. In some
instances, the discrimination may be continuing. For example, seniority lines are segregated.
Question 8: Tell us as much as you can. For example: Were you fired? Did you fail to get a promotion? Did the
company refuse to hire you? Did the union or employment agency refuse to refer you to a job? Who discriminated
against you? Why do you believe it was because of your race, color, religion, national origin, sex, age or other?
Question 9: Sign your name, and mail or take the completed complaint form to the Mercer County Branch NAACP, 700 Hamilton Avenue, Farrell, PA 16121
Sincerely,
Legal Redress Committee
Mercer County Branch NAACP
700 Hamilton Avenue
Farrell, PA 16121
COMPLAINT OF DISCRIMINATION
Completing this form does not constitute filing an official complaint with a legal authority.
At this time, the NAACP is only seeking information to assist you concerning this complaint. Please answer all
questions and be as specific as possible.
MAIL OR DELIVER TO
Mercer County Branch NAACP, 700 Hamilton Avenue, Farrell, PA 16121
(Please print or type)
QUESTION 1:
YOUR NAME
PHONE NUMBER
STREET ADDRESS
CITY, STATE
ZIP CODE
QUESTION 2:
WAS THE DISCRIMATION BECAUSE OF: (Please check those that apply)
RACE OR COLOR
RELIGION
NATIONAL ORIGIN
SEX
AGE
HANDICAPPED STATUS
OTHER
QUESTION 3:
WHO DISCRIMINATED AGAINST YOU? GIVE NAME AND ADDRESS OF EMPLOYER, LABOR
ORGANIZATION, EMPLOYMENT AGENCY, APPRENTICESHIP COMMITTEE, LICENSING
AGENCY, ETC. (List all)
NAME
AND (Other parties, if any)
STREET ADDRESS
CITY, STATE
ZIP CODE
QUESTION 4:
HAVE YOU FILED A COMPLAINT WITH
ANY GOVERNMENTAL AGENCIES? IF SO, WHICH ONE(S)?
YES
NO
QUESTION 5:
HAVE YOU FILED A GRIEVANCE
WITH YOUR UNION?
YES
NO
NAME OF LOCAL REPRESENTATIVE:
QUESTION 6:
HAVE YOU RETAINED AN ATTORNEY REGARDING THIS CASE?
YES
NO
IF YES:
NAME OF ATTORNEY
PHONE
ADDRESS
QUESTION 7:
THE ACTUAL DATE OR THE MOST
RECENT DATE ON WHICH DISCRIMINATION OCCURRED:
DAY OF MONTH
TIME OF DAY ______ AM/PM
DISCRIMINATION OCCURRED:
MONTH
YEAR
QUESTION 8:
EXPLAIN WHAT UNFAIR THING WAS DONE TO YOU:
(Attach additional paper if needed)
QUESTION 9:
I AFFIRM THAT I HAVE READ THE ABOVE COMPLAINT AND THAT IT IS TRUE TO THE
BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.
SIGNATURE OF COMPLAINTANT: X___________________________________
DATE:____________________________________
RELEASE AND DISCLAIMER
I, _____________________________________, reside at_______________________________________. By
placing my Initials to the left of each numbered item below, I affirm that I understand it and agree with it.
____ 1. I have submitted to the San Jose/Silicon Valley Branch of the NAACP a Complaint of Discrimination
directed against ________________________ (Respondent).
_____2. I understand that the NAACP is a private, nonprofit, voluntary organization. It is not a government
agency. Filing a complaint with the NAACP is not the same as filing a complaint with an administrative agency or
filing a law suit in a court of law. Whatever rights I have to file a complaint with an administrative agency or to file a
civil lawsuit are completely unaffected by filing this complaint with the NAACP.
_____3. The deadline by which I must file my complaint or lawsuit with ____________________________ is
__________________________. If I do not file my complaint or lawsuit with _________________________by
that time, I may not have a right to recover for any harm from the respondent.
_____4. I have authorized the NAACP to investigate my complaint; (2) to attempt to mediate my complaint with
Respondent in order to explore the possibility of settlement; and (3) if there is no settlement, to provide me at least
three referrals of lawyers who may consider representing me in litigation against Respondent.
_____5. I understand that the NAACP in no way guarantees the competency, professionalism or fitness of the
lawyers whose names have been provided.
_____6. I will provide the NAACP copies (not originals) of whatever documents I have to support the complaint.
If I request in writing that some of the material will be held in confidence, the NAACP will hold it in confidence;
otherwise the NAACP may share it with the Respondent or with state or federal anti-discrimination agencies.
_____7. If the NAACP mediates my complaint with Respondent, I will refrain from filing my complaint with a
state or federal anti-discrimination agency, or filing a lawsuit while the mediation is in progress. However, I am free
at any time, after notifying the NAACP of my intentions, to terminate the mediation and file a complaint with a
state or federal anti-discrimination agency or file a lawsuit. If the mediation is nonbinding, I am not required to
accept a settlement with Respondent.
_____8. NAACP will receive no funds from any mediation or settlement. Persons conducting settlement and
negotiations are not lawyers and are not providing legal services.
_____9. I agree that if I accept a settlement with Respondent, I will be required to sign a release of Claims against a
Respondent, and I will honor the terms of such a Release and Claim.
_____10. I understand that if the NAACP refers me to a private attorney, I am not required to retain him/her and
s/he is not required to offer legal representation to me. I understand that such representation need not be without
charge, but may be on whatever terms agreed upon. I understand that s/he does not also represent the NAACP,
nor is s/he employed or paid by the NAACP.
_____11. I understand that the NAACP is not a law firm and cannot provide me with legal advice or legal
representation. Although some of its members and volunteers are lawyers, they represent the NAACP and not me
personally.
______12. I release and hold harmless the NAACP, its officers, directors, employees, agents, personal actions and
actions, cause and causes of action, suits, debts, dues, sums of money, accounts, reckonings, bonds, bills, specialties,
covenants, contracts, controversies, agreement, promises, variances, trespasses, damages, judgments, executions,
claims and demands whosoever in law and in equity, which I ever had, may have in the future, or which any of my
personal representatives, successors, heirs or assigns hereafter can, shall or may have against the NAACP, upon or
by reason of the NAACP’s handling of my Complaint of Discrimination.
Complaint Form
NATIONAL ASSOCIATION FOR THE ADVANCEMENT OF COLORED PEOPLE
COMPLAINT GUIDELINES
Please read each attached page carefully. Please complete this form, have it notarized and return to:
Mercer County Branch NAACP
700 Hamilton Avenue
Farrell, PA 16121
Phone: (724) 981-4140
Fax: (724) 981-1324
email:farrellnaacp@verizon.net
PLEASE NOTE:
• The NAACP cannot help you with your civil rights complaint until this form has been completed
and returned;
• Thorough completion of this form will help to expedite the handling of your complaint;
• The sheer volume of complaints received prevents the NAACP from pursuing every matter. Our
ability to assist is directly related to membership support. We do not receive financial support from
the government.
FILING A CIVIL RIGHTS COMPLAINT
To process a civil rights complaint, the individual must be able to provide enough information to
reasonably establish that there has been a violation of the law. To establish grounds, it will be helpful
to the investigating agency if you can provide the following information:
• The name, address and telephone number of the person or business against whom you are
complaining and, for employment complaints, your best estimate of the total number of persons
employed by the business;
• The dates of all alleged discriminatory incidents and the names of everyone involved;
• Specific examples of different/discriminatory treatment, indicating the people and conduct
involved;
• Names, addresses and telephone numbers (if possible) of all witnesses;
• Copies of any relevant policies and/or documents;
• For an employment complaint that involves a union, the name, address and telephone number of
the union local and the relevant representative, including the status of any filed grievance(s);
• Copies of any complaints filed with any state or federal agency.
INFORMATION TO CONSIDER WHEN
FILING A CIVIL RIGHTS COMPLAINT
• If it is an employment matter, it can still be referred to the Equal Opportunity Commission
(EEOC) if the alleged discriminatory act(s) occurred within the past 300 days;
• You should be able to provide a reason for your belief that the act(s) occurred because of religion,
race, color, national origin, age1
, sex, height2
, weight3
, marital status4
, familial status5
, physical or
mental disability, arrest record6
, or in retaliation for making or participating in a complaint about
one of these categories;
• The alleged discriminatory act(s) occurred in Santa Clara County;
• The person or entity against who you are complaining is not a United States, Canadian or Native
American governmental agency;
• The matter is not pending in any court of law
1 In education issues, age and marital status applies only to records made for admission purposes. 2 Height, weight and arrest record apply to employment only. 3 See Footnote #2, above. 4 See Footnote # 1, above. 5 Applies to housing only. 6 See Footnote #2, above.
NAACP COMPLAINT FORM
(Please PRINT or TYPE)
Dear ____________ Community Member:
San Jose/Silicon Valley Branch NAACP will refer complaints alleging employment discrimination to an
appropriate agency for official investigation, i.e., EEOC or Local Human Rights Commission and monitor the
agency’s work on all cases referred by the NAACP. Completing this form does not constitute filing an official
complaint with a legal authority.
To the extent resources allow, the San Jose/Silicon Valley Branch of the NAACP may provide other supportive
assistance to the complainant. In virtually all instances of employment discrimination, complainants will lose their
right to any form of legal remedy if they do not file a complaint with the EEOC within 180 days of the event of
the alleged discriminatory conduct and/or act. Please answer all questions and be as specific as possible. These
directions are numbered to match the questions.
Question 1: Be sure to give your full name and address. If you do not have a phone, give a phone number where
you can be reached.
Question 2: Please check the box that indicates what you believe to be the cause of discrimination (if other, please
state what other).
Question 3: If you believe that other parties (for example, a labor union or any employment agency, in addition to
an employer) were involved in the act of discrimination, list them on the last line of section 3.
Questions 4, 5 and 6: If you have consulted an attorney or filed this complaint with a state or local human relations
commission, Federal government, union or agency, check “yes” and give the name of the entity.
Question 7: Give the day, month and year of the most recent incident when discrimination took place. In some
instances, the discrimination may be continuing. For example, seniority lines are segregated.
Question 8: Tell us as much as you can. For example: Were you fired? Did you fail to get a promotion? Did the
company refuse to hire you? Did the union or employment agency refuse to refer you to a job? Who discriminated
against you? Why do you believe it was because of your race, color, religion, national origin, sex, age or other?
Question 9: Sign your name, and mail or take the completed complaint form to the Mercer County Branch NAACP, 700 Hamilton Avenue, Farrell, PA 16121
Sincerely,
Legal Redress Committee
Mercer County Branch NAACP
700 Hamilton Avenue
Farrell, PA 16121
COMPLAINT OF DISCRIMINATION
Completing this form does not constitute filing an official complaint with a legal authority.
At this time, the NAACP is only seeking information to assist you concerning this complaint. Please answer all
questions and be as specific as possible.
MAIL OR DELIVER TO
Mercer County Branch NAACP, 700 Hamilton Avenue, Farrell, PA 16121
(Please print or type)
QUESTION 1:
YOUR NAME
PHONE NUMBER
STREET ADDRESS
CITY, STATE
ZIP CODE
QUESTION 2:
WAS THE DISCRIMATION BECAUSE OF: (Please check those that apply)
RACE OR COLOR
RELIGION
NATIONAL ORIGIN
SEX
AGE
HANDICAPPED STATUS
OTHER
QUESTION 3:
WHO DISCRIMINATED AGAINST YOU? GIVE NAME AND ADDRESS OF EMPLOYER, LABOR
ORGANIZATION, EMPLOYMENT AGENCY, APPRENTICESHIP COMMITTEE, LICENSING
AGENCY, ETC. (List all)
NAME
AND (Other parties, if any)
STREET ADDRESS
CITY, STATE
ZIP CODE
QUESTION 4:
HAVE YOU FILED A COMPLAINT WITH
ANY GOVERNMENTAL AGENCIES? IF SO, WHICH ONE(S)?
YES
NO
QUESTION 5:
HAVE YOU FILED A GRIEVANCE
WITH YOUR UNION?
YES
NO
NAME OF LOCAL REPRESENTATIVE:
QUESTION 6:
HAVE YOU RETAINED AN ATTORNEY REGARDING THIS CASE?
YES
NO
IF YES:
NAME OF ATTORNEY
PHONE
ADDRESS
QUESTION 7:
THE ACTUAL DATE OR THE MOST
RECENT DATE ON WHICH DISCRIMINATION OCCURRED:
DAY OF MONTH
TIME OF DAY ______ AM/PM
DISCRIMINATION OCCURRED:
MONTH
YEAR
QUESTION 8:
EXPLAIN WHAT UNFAIR THING WAS DONE TO YOU:
(Attach additional paper if needed)
QUESTION 9:
I AFFIRM THAT I HAVE READ THE ABOVE COMPLAINT AND THAT IT IS TRUE TO THE
BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.
SIGNATURE OF COMPLAINTANT: X___________________________________
DATE:____________________________________
RELEASE AND DISCLAIMER
I, _____________________________________, reside at_______________________________________. By
placing my Initials to the left of each numbered item below, I affirm that I understand it and agree with it.
____ 1. I have submitted to the San Jose/Silicon Valley Branch of the NAACP a Complaint of Discrimination
directed against ________________________ (Respondent).
_____2. I understand that the NAACP is a private, nonprofit, voluntary organization. It is not a government
agency. Filing a complaint with the NAACP is not the same as filing a complaint with an administrative agency or
filing a law suit in a court of law. Whatever rights I have to file a complaint with an administrative agency or to file a
civil lawsuit are completely unaffected by filing this complaint with the NAACP.
_____3. The deadline by which I must file my complaint or lawsuit with ____________________________ is
__________________________. If I do not file my complaint or lawsuit with _________________________by
that time, I may not have a right to recover for any harm from the respondent.
_____4. I have authorized the NAACP to investigate my complaint; (2) to attempt to mediate my complaint with
Respondent in order to explore the possibility of settlement; and (3) if there is no settlement, to provide me at least
three referrals of lawyers who may consider representing me in litigation against Respondent.
_____5. I understand that the NAACP in no way guarantees the competency, professionalism or fitness of the
lawyers whose names have been provided.
_____6. I will provide the NAACP copies (not originals) of whatever documents I have to support the complaint.
If I request in writing that some of the material will be held in confidence, the NAACP will hold it in confidence;
otherwise the NAACP may share it with the Respondent or with state or federal anti-discrimination agencies.
_____7. If the NAACP mediates my complaint with Respondent, I will refrain from filing my complaint with a
state or federal anti-discrimination agency, or filing a lawsuit while the mediation is in progress. However, I am free
at any time, after notifying the NAACP of my intentions, to terminate the mediation and file a complaint with a
state or federal anti-discrimination agency or file a lawsuit. If the mediation is nonbinding, I am not required to
accept a settlement with Respondent.
_____8. NAACP will receive no funds from any mediation or settlement. Persons conducting settlement and
negotiations are not lawyers and are not providing legal services.
_____9. I agree that if I accept a settlement with Respondent, I will be required to sign a release of Claims against a
Respondent, and I will honor the terms of such a Release and Claim.
_____10. I understand that if the NAACP refers me to a private attorney, I am not required to retain him/her and
s/he is not required to offer legal representation to me. I understand that such representation need not be without
charge, but may be on whatever terms agreed upon. I understand that s/he does not also represent the NAACP,
nor is s/he employed or paid by the NAACP.
_____11. I understand that the NAACP is not a law firm and cannot provide me with legal advice or legal
representation. Although some of its members and volunteers are lawyers, they represent the NAACP and not me
personally.
______12. I release and hold harmless the NAACP, its officers, directors, employees, agents, personal actions and
actions, cause and causes of action, suits, debts, dues, sums of money, accounts, reckonings, bonds, bills, specialties,
covenants, contracts, controversies, agreement, promises, variances, trespasses, damages, judgments, executions,
claims and demands whosoever in law and in equity, which I ever had, may have in the future, or which any of my
personal representatives, successors, heirs or assigns hereafter can, shall or may have against the NAACP, upon or
by reason of the NAACP’s handling of my Complaint of Discrimination.
Dated________________________________
Agreed______________________________
OFFICE USE ONLY. DO NOT WRITE ON THIS PAGE!
SUMMARY/FINDINGS:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
DISPOSITION:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Reviewer’s Name: _____________________________ Date: __________________