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: _____________

What is the service requested of the ACLU? ___________________________________________

Complaint Description

Please provide below a brief description of your complaint.

IMPORTANT – DATE IN WHICH LEGAL ACTION BECOMES TIMED BARRED:

_________________________________________________________________________________

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 00918

FAX:  (787) 753-4268
Email: aclupr@prtc.net

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