[City of Salina] CR Complaint Intake

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***

Para completar el formulario de admision de quejas en español, visite: https://salinaks.seamlessdocs.com/f/sce3zo4o0l29

Type of Complaint

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

Employment

Housing

Public Accommodations

Complainant Information (You):

Home Phone Number

Work Phone Number

I prefer to be contacted at:

Days:

Time:

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

Name: *

Telephone Number: *

Relationship: *

What is your marital status?

Are you currently employed?

What is your annual / hourly income?

Do you receive government assistance?

Check any / all that apply:

TANF

General Relief

Food Stamps

Section 8

SSI

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

Title

If other, please speciify:

Phone Number

Is there more than one person that has discriminated against you?

Title

If other, please speciify:

Phone Number

Complaint Information

Job Location:

Job Title:

Salary:

Date of Hire OR Hire Denial:

Date of Termination:

Supervisor:

Unit Location:

Rent (week/month) $:

Lease?

Yes

Length of Lease:

Deposit $:

Pet Deposit $:

Date Moved in OR Date Refused:

Business or Public Area where incident occurred (Be specific):

Date of Incident:

Approximate time of Incident:

Please use this space to specify or add information regarding the previous question

Please note incident(s) you feel are discriminatory in nature. List according to date, earliest to latest, and include date (please feel free to add an attachment with any additional information):

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:

Name, Address, Telephone Number Remove Field

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Settlement Information:

What do you feel would resolve the issue between you and the Respondent, and settle your complaint against them? Be as specific as you can. We will use this information to set up resolution between you and the Respondent: If you are unsure at this time, please indicate that.

How did you learn about the Community Relations Division?

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."

I swear or affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.

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Last Name

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