Have you been jailed for failure to pay fines?

1. Complaint Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip *

Daytime Phone *

Evening Phone

Email *

2. The court I appeared In

Name of Judge or Magistrate

Street Address

Address Line 2

City

State

Zip Code

Phone

3. Date of situation giving rise to your complaint

Date

Month

Day

Year

4. Witnesses or persons with information about your complaint

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone

May we contact this person?

Yes

5. Have you filed a complaint with any other agencies?

Yes

If yes, please describe in the following space and include the dates.

7. Current representation

Are you represented by an attorney in this matter?

Yes

If yes, please provide the following:

Attorney's First Name

Attorney's Last Name

Agency or Law Firm

Street Address

Address Line 2

City

State

Zip Code

Phone

8. Pending lawsuits

Has a criminal or civil lawsuit been filed against you or on your behalf?

Yes

If so, please provide the following:

Case Number

Case Title

Date of Filing

Court With Jurisdiction

Judge

Opposing Counsel

Current Status of the Case

9. Complete description of complaint.

Please describe IN DETAIL, in a brief summary, all the events that led you to file this complaint.

State clearly what you would like the ACLU to do for you.

Disclaimer and Notice

This Survey does not give legal advice, and you should not rely on it as legal advice. You should not rely on the information you get from this site and should speak with a lawyer to get advice on your specific situation. We also cannot promise that the information on this site is complete, accurate, or up-to-date.

This Survey is not a solicitation or an offer by the American Civil Liberties Union and its affiliates to represent you. We cannot promise you that the information you provide will lead to any specific action on the American Civil Liberties Union or its affiliates part. Once you complete the survey, the American Civil Liberties Union of Ohio may not do anything—including contact you—about your situation.

If you fill out this Survey, you agree that the American Civil Liberties Union, the national ACLU or its affiliates, if identified as part of the Survey, or one of its coalition partners may use the information you give us, as long as we don’t include your name, address, email or phone number, for one or more of the following purposes: (1) legislative testimony, (2) litigation; (3) contacting a city, state or federal agency; or (4) telling your story to the public, including the media. If the American Civil Liberties Union, the national ACLU or its affiliates, or one of its coalition partners wants to identify you, we will contact you prior to doing so.

We will keep your name, address, telephone number and email confidential unless you give us permission to use it or unless we are ordered to turn it over by a court (although we will attempt to prevent any disclosure).

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