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City of Salina

support@salina.org

300 W Ash, Salina, KS, 67401, US

 

COMPLAINT INTAKE FORM
SALINA HUMAN RELATIONS COMMISSION


SALINA COMMUNITY RELATIONS DIVISION
P.O. Box 736 - 300 West Ash - Salina, KS 67401
Office: 785-309-5745 - FAX: 785-309-5745

 

Please answer the following questions, telling us briefly why you feel you have been discriminated against. Answer all questions as completely as possible. If you have already filed with a STATE or FEDERAL AGENCY, or if your complaint is about something that happened over 1 year ago, STOP and call our office. Upon completing this form, submit the electronic form and we will call to set up an appointment to talk with you concerning your complaint intake information.

***Please be advised that housing complaints are dually filed with the U.S. Department of Housing and Urban Development***

Type of Complaint

If you have more than one complaint, please fill out a separate form for each complaint.

Complainant Information (You):

Full Name

Date of Birth

Full Address

I prefer to be contacted at:

Please provide the name of a person at a different address whom we can contact when unable to reach you:

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Respondent Information (Person who you believe is discriminating against you):

Full Name

Full Address

Full Name

Full Address

Complaint Information

Lease?

"I believe I was discriminated against because of my..." (Check all applicable)

Upload any additional information regarding Incident(s) you feel are discriminatory

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List names, addresses and telephone numbers of witnesses, and give description of the information they can provide that would support your allegations:

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Settlement Information:

This complaint is filed under the Salina City Code, Chapter 13, Equal Opportunity and Affirmative Action Ordinance.
Sec. 13-83. Submission of a false, misleading or incomplete complaint, statement, response or report states:
“Any person who knowingly and intentionally submits or files or causes to be submitted or filed, a false, misleading, or incomplete complaint, statement, response or report with the commission, the director or any of the department’s personal, shall be guilty of a misdemeanor."

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