INSTRUCTIONS: CONNECTICUT DISCRIMINATION COMPLAINT/FEDERAL GRANTS

To file a complaint in Connecticut regarding discrimination by a program or activity supported by the U.S. Department if Justice, use the form discussed in this article. This document can be obtained from the website of the Connecticut Judicial Branch.

Connecticut Discrimination Complaint/Federal Grants Step 1: Enter the name of the person filing the complaint in the first blank box.

Connecticut Discrimination Complaint/Federal Grants Step 2: Enter your telephone number in the second blank box.

Connecticut Discrimination Complaint/Federal Grants Step 3: Enter your full address in the third blank box.

Connecticut Discrimination Complaint/Federal Grants Step 4: In the next section, enter the name of the subrecipient against whom you are filing the complaint, as well as their address and telephone number.

Connecticut Discrimination Complaint/Federal Grants Step 5: Indicate whether your complaint involves employment or failure to receive services by placing an "x" next to the appropriate statement.

Connecticut Discrimination Complaint/Federal Grants Step 6: The next section concerns the basis for your complaint. Place an "x" in the first box if your complaint involves discrimination on the basis of age.

Connecticut Discrimination Complaint/Federal Grants Step 7: Place an "x" in the second box if your complaint involves discrimination on the basis of race or ethnicity.

Connecticut Discrimination Complaint/Federal Grants Step 8: Place an "x" in the third box if your complaint involves discrimination on the basis of color.

Connecticut Discrimination Complaint/Federal Grants Step 9: Place an "x" in the fourth box if your complaint involves discrimination on the basis of religion.

Connecticut Discrimination Complaint/Federal Grants Step 10: Place an "x" in the fifth box if your complaint involves discrimination on the basis of sex or gender.

Connecticut Discrimination Complaint/Federal Grants Step 11: Place an "x" in the sixth box if your complaint involves discrimination on the basis of a physical or mental disability.

Connecticut Discrimination Complaint/Federal Grants Step 12: Place an "x" in the seventh box if your complaint involves discrimination on the basis of national origin.

Connecticut Discrimination Complaint/Federal Grants Step 13: Describe the alleged discriminatory act, including dates, locations, names and contact information of witnesses. Attach additional pages if necessary.

Connecticut Discrimination Complaint/Federal Grants Step 14: Sign and date the form where indicated.