Complaint Form

Please print this form out and mail it to us at the indicated address.  We cannot accept e-mailed or faxed versions. 

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Mail to: ACLU of Louisiana                                               FOR ACLU USE ONLY:

            Protecting Our Rights                                          Type of Complaint:

            P. O. Box 56157                                                   Recommendation:

            New Orleans, LA  70156-6157                               Disposition/Date:

IMPORTANT:  Before completing, please read the entire form carefully.  TYPE or PRINT CLEARLY.

Sign and date the last page.

Complainant Information

Name:  Last                                                      First                                                      M.I.          

Address:                                                                                City:                                   State:           ZIP:           

Day Phone:   (         )                                  Night Phone:  (          )                                   

email address __________________________________________

Respondent Information – My complaint is against the following:

Name:  Last                                                      First                                                      M.I.          

Company/Government Agency (if applicable):                                                                                   

Address:                                                                             City:                                     State:           ZIP:            

Phone:   (         )                                    Fax:   (         )                             

Date of Act giving rise to this complaint:                                                 

May we contact this person?                Yes                       No

If more than one respondent, please provide the information on a separate sheet.

Have you filed a complaint with any other agencies?        Yes              No

If yes, please describe and include dates:                                                                                                         

Are you represented by an attorney in this matter?          Yes               No

If yes, Attorney's Name: Last                                                                First                                                M.I.         

Address:                                                                            City:                                         State:            ZIP:            

Phone:   (         )                                    Fax:   (         )                           

Has a criminal or civil lawsuit been filed against you or on your behalf?          Yes             No

If yes, Case Title:                                                 Case Number:                          Date Filed:                          

Court:                                                                                 Judge:                                                                

Opposing Attorney:                                                  Current Status of Case:                                                   

Description of Complaint:   Please type or print clearly.

Describe the events that led you to file this complaint.  

Include pertinent facts, such as date, person, place, summary and what was said or done to you or to the hurt person.

If there is not sufficient space, please attach ONE additional page to complete your explanation.  If you send more that one additional page, it will not be read.  If we require further information to determine if we can be of assistance, we will contact you for more information. 

DO NOT SEND ANY ADDITIONAL DOCUMENTATION.  The ACLU is not responsible for the maintenance or return or any documentation we receive.

Are you willing to serve as a plaintiff in litigation if needed?          Yes              No

I hereby certify that I have read the information contained in this complaint form
and that all of the 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
is not undertaking legal representation of me, and that the ACLU is not responsible
for ensuring that any statute of limitations or prescriptive period is met in my case. 
I hereby authorize the ACLU to use this information in any manner it deems necessary.

SIGNATURE:                                                                               DATE:                                    

                                                   (signed) 

                                                   (printed)