Louisiana Justice Foundation-Louisiana National Action
      Louisiana.NationalAction@1LaJustice.net
P O Box 401
Sicily Island, Louisiana 71368-0401

                   CIVIL RIGHTS
COMPLAINT QUESTIONNAIRE
                           	Louisiana Justice Foundaton
Accepted           ”
Not Accepted   ”

Date:  ______________________________________

Intake Officer: _______________________________
                                                                                                     
Complaint Number: ___________________________	

 Last Name                                                   First Name                                                             Middle Initial	

Street Address                                                                                                                             Parish	

City                                                               State                                                                        Zip Code	

 Age	

    Date of Birth	

Sex    	

Race        	

    Marital Status  	

Telephone Number	
I believe I have been discriminated against in:
   
Civil Justice System____              Economic Development____      Civil Rights____    Human Rights____
Educational System____              Employment___                          Criminal Justice System____  
	
I believe I have been discriminated against because of:

Race_____     Color_____     Sex_____     Age_____     Disability_____    Religion_____     National Origin_____    

State Repression_____         Racial Profiling_____      Retaliation______
                                                                                                                         	
Entity or Agency of Authority Which committed Act:  

Name________________________________________________________________________________________

Address______________________________________________________________________________________

City__________________________________State__________________ZipCode________Parish_____________

Number involved_________________         Date of last act of alleged discrimination                                   

Telephone                                      Name of Person who allegedly discriminated against you_______________                                  	
Are you presently involved with the Entity that you believe discriminated against you?   Yes_____    No_____

Dates of incidents_____________________________

Actual Perpertrator________________________________________

Have you filed a complaint with any agency or group other than this office?

_____Yes (If so, complete the area below)               _____No

Name __________________________________________

Address ________________________________________   

Phone Number___________________________________

Results, If any____________________________________ 

Sign here if you agree to have the results of the above-mentioned investigation released to the Louisiana 

Louisiana Justice Foundation___________________________________________
	
If you have an Attorney, please provide the Attorney’s name, address and telephone number.

________________________________________________________________________________________     
	
Briefly explain the action taken that you believe to be discriminatory.__________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

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I solemnly swear or affirm that all of the information provided on this form is true and accurate to the best of my knowledge.

Signature____________________________________                                            Date_________________

Louisiana Justice Foundation
Louisiana National Action
Post Office Box 401
 Sicily Island, Louisiana 71369-0401

COMPLAINANT’S CONSENT FOR INVESTIGATORY 
USE OF PERSONAL INFORMATION

1.	 I understand that I am not required to give personal information to the LJF; however, my complaint may be closed if I refuse to supply information needed to investigate my complaint;

2.	I understand that it is my duty to update the personal information I supply and failure to do so may result in my complaint being closed;

3.	I understand that I may receive a copy of any personal information I submit, if I request it; and

4.	I understand that the information provided by me may have to be released under the Public Records Request.

	
Based on the foregoing, I hereby give my consent to LOUISIANA JUSTICE FOUNDATION to process my complaint.

																												
	_________________________________		_________________
			Signature					Date

NOTE:		THE LOUISIANA JUSTICE FOUNDATION RESERVES THE RIGHT TO MODIFY THIS FORM WITHOUT NOTICE OR CONSENT.