Capital Good Fund Civil Rights Complaint Form

Section 1: Complainant Contact/Personal Information

Are you a current employee or an external stakeholder?

Current Employee
External Stakeholder

Name

First

Middle

Last

Home Phone Number

Cell Phone Number

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Preferred Method of Contact

Home Phone
Cell Phone
Email

Best Time to Reach You

Section 2: Representative Information

Do you have a Representative?

Yes
No

Is your Representative an attorney?

Yes
No

Firm's Name (if applicable)

Representative's Phone Number

Representative's Email Address

Section 3: Complaint Information

Is this a recurring discriminatory act?

Yes
No

If yes, provide the most recent date of alleged discrimination.

Where the alleged act/event occurred:

Date the alleged act/event occurred:

You are alleging discrimination on which basis? Check all that apply.

Please explain what happened to you. Email any supporting documents to [email protected].

Please explain how you would like to see this complaint resolved.

name alleged current

I certify that I am the individual submitting this document. (Enter your name below to sign)

Date

FILING DEADLINE: You must file your complaint no later than 180 days from the date you became aware of the alleged discrimination. Complaints sent by email will be considered filed on the date the complaint is received. Complaints filed after the 180-day deadline must include a "good cause" explanation for the delay. Examples of "good cause" include: 1. You could not reasonably have been expected to know of the discriminatory act within the 180-day period; 2. You were seriously ill or incapacitated; or 3. The same complaint was filed with another federal, state, or local agency and that agency failed to act on your complaint

DISCLOSURE: Providing this information is voluntary. Failure to complete this form may lead to a delay in processing of the complaint, or rejection of the complaint due to an inadequate basis to continue processing.