ACLU of the District of Columbia Intake Form

Important: Must be filled out in full. Before completing form, please read all parts carefully.

* indicates required field

1. WHO IS MAKING THIS COMPLAINT?

First Name *

Middle Name

Last Name *

What are your gender pronouns? (In other words, when we refer to you in the third person, how would you like us to do so?) *

Other

Street Address *

City *

State *

Zip Code *

County

Email *

Phone (day) *

Phone (evening)

2. MY COMPLAINT IS AGAINST THE FOLLOWING

First Name

Middle Name

Last Name

Government Agency

Street Address

City

State

Zip Code

County

Phone

May we contact this person/agency?

Yes

Click to add more than one person or agency

First Name

Middle Name

Last Name

Government Agency

Street Address

City

State

Zip Code

Country

Phone

May we contact this person/agency?

Yes

3. DATE OF GOVERNMENTAL ACT GIVING RISE TO YOUR COMPLAINT

Month

Day

Year

4. WITNESSES OR PERSONS WITH INFORMATION REGARDING YOUR COMPLAINT

First Name

Middle Name

Last Name

Street Address

City

State

Zip Code

County

Phone (day)

Phone (evening)

May we contact this person/agency?

Yes

CLICK HERE TO ADD ADDITIONAL WITNESSES OR PERSONS WITH INFORMATION REGARDING YOUR COMPLAINT

First Name

Middle Name

Last Name

Street Address

City

State

Zip Code

County

Phone (day)

Phone (evening)

May we contact this person/agency?

Yes

5. HAVE YOU FILED A COMPLAINT WITH ANY OTHER AGENCIES?

Yes

(Examples: complaint filed with police department, discrimination complaint filed with equal employment opportunity office in company or agency.)

If yes, please describe

6. ARE YOU REPRESENTED BY AN ATTORNEY IN THIS MATTER?

Yes, I'm represented by an attorney in this matter

No, I'm not represented by an attorney in this matter

Attorney's First Name

Attorney's Middle Name

Attorney's Last Name

Street Address

City

State

Zip Code

County

Phone

May we contact this person/agency?

Yes

7. WHAT, IF ANYTHING, HAVE YOU DONE TO ADDRESS THE PROBLEM? (filed grievances, submitted complaints to other agencies, etc.)

8. COMPLETE DESCRIPTION OF COMPLAINT:

Describe IN DETAIL the events that led you to file this complaint with ACLU.

9. PLEASE STATE YOUR GOAL CLEARLY: WHAT YOU WOULD LIKE THE ACLU TO DO FOR YOU?

10. How did you hear about us?

For example, did you hear about us from another community member? Did an ACLU of D.C. staff member encourage you to submit a request? Did a local legal services provider give you our information?

(Your answer will have no impact on how we determine if we can help you. We ask this question to better understand the impact of our community outreach efforts.)

Please check the box to indicate that the information you have provided is true and correct to the best of your knowledge; that you understand that by accepting this complaint, the ACLU of the District of Columbia is not undertaking legal representation of you; and that the ACLU of the District of Columbia is not responsible for ensuring that any statute of limitations requirement or any other requirement or deadline is met in your case.

Please note: We will keep confidential what you tell us, unless you give us permission to share it or unless we are ordered to turn it over by a court. We respond to all intake requests within 4-6 weeks, often sooner if you include your email or mailing address and not just your phone number.

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