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2. 
3. City of Storm Lake Discrimination Complaint Form
5. Name*
6. Phone Number:*
8. Address*
   City, State Zip Code
9. Email:
11. Basis of Complaint ( check all that apply);*

    1. Race
    2. Color

    1. National Origin
    2. Sex/Gender

    1. Age
    2. Disability

    1. Retaliation
13. Are you a City of Storm Lake employee?*

    1. Yes
    2. No
14. Is this complaint against the City of Storm Lake?*

    1. Yes
    2. No
15. Is this complaint against a City of storm Lake employee?*

    1. Yes
    2. No
17. Who discriminated against you?
18. Name:*
20. Name of Organization:
22. Address:
23. Phone Number:
25. How were you discriminated against?
27. Where did the discrimination occur?
29. Date and times discrimination occurred?
31. Were there any other witnesses to the discrimination?
33. Name:
34. Organization:
35. Phone Number:
37. Name:
38. Organization:
39. Phone Number:
41. How would you like to see this situation resolved?
43. Have you filed your complaint or lawsuit with any other agency or court?
45. Who:
46. When:
48. Status of complaint:
    -- Select One --PendingResolved
49. Result, if known:
50. Complaint number, if known:
52. Do you have legal representation in this matter?

    1. Yes

    1. No
53. Name:
55. Phone Number:
56. Address:
58. Signature*
59. Date:
    Date:
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field