COMPLAINT FORM Please print this page or download form (Word) |
Complainant Information:
Last Name __________________________________ Name ________________ Initial ___
Address: _________________________________________________________________________
City: ______________________ State: ___________ Zip Code: __________________
Day Time Telephone: _________________________ Evening Telephone: ________________
Email: ________________________________ Cellular: _________________________
My complaint is against the following:
Agency: _________________________________________________________________________
Last Name _________________________________ Name ________________ Initial ___
Address: _________________________________________________________________________
City: ______________________ State: ___________ Zip Code: __________________
Day Time Telephone: _______________________ Evening Telephone: _____________________
Date of situation giving rise to your complaint: __________________________________________
May we contact this person? ___________ Yes ________________ No
Witnessess or persons with information regarding your complaint: ____________________________
__________________________________________________________________________________
__________________________________________________________________________________
Have you filed a complaint with any other agencies? ___________ Yes ________________ No
_________________________________________________________________________________
Provide details and dates: ____________________________________________________________
Are you represented by an attorney in this matter? ___________ Yes ________________ No
If so, please provide the following information on the attorney:
Last Name _______________________________ Name ___________________ Initial _____
Address: __________________________________________________________________________
City: ______________________ State: ___________ Zip Code: ___________________
Day Time Telephone: ___________________________ Fax: _____________________________
Email: ________________________________ Cellular: _________________________
Has a criminal or civil lawsuit been filed against you or on your behalf? _______ Yes ______ No
If so, please provide:
Case Title: _______________________ Case Number: __________________
Date of filing: ___________ Court with jurisdiction: ________________ Judge: ________________
Opposing counsel: ____________________________ Current status of the case: _____________
Complaint Description
Please provide below a brief description of your complaint.
I understand that by receiving this complaint, the ACLU is not undertaking legal representation on my behalf, and that the ACLU is not responsible for ensuring that any statute of limitations requirement is met in my case. I hereby authorize the ACLU to use this information as necessary to determine whether it will offer legal assistance and as to determine whether my situation represents an emerging civil liberties issue or is part of a pattern and practice of civil liberties and/or civil rights violations that should be redressed in this present or future case.
Signature: _______________________________________ Date: ____________________________
You may email or send this request for assistance by regular mail to:
ACLU of Puerto Rico
Union Plaza, Suite 205
416 Ponce de León Avenue
San Juan, Puerto Rico 00918FAX: (787) 753-4268
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