IER Charge Form

Employer name: *

Street or mailing address:

Suite:

City: *

State: *

Zip Code:

Telephone:

If you know, does the Employer operate under any other names?
YesNo

If yes, under what other name(s)?

Number of employees the Employer employs: *
Fewer than 4
4-14
15 or more
Don't know/Unable to estimate

When did the discrimination occur?
(Month) * (Day) (Year) *

Where did the discrimination occur?

Place:

City: *

State: *

Explain in detail what happened when the Injured Party was discriminated against. *
Include whether the Injured Party was fired, laid-off, not hired, delayed in starting work, asked for additional documents, retaliated against, or other, and describe what happened in detail. (Attach additional sheets if needed. If the Injured Party has any documents to support the claim, you may attach them. Please only send copies of documents, not originals.)

3980 /3980 characters remaining.

Filing Supporting Documents

You cannot attach supporting documents directly to this form. If you want to submit other documents, you can do so by using the following instructions. Please only send copies of documents, not originals. When transmitting attachments or documents relating to this form, please include the reference number that will generate once you have submitted the form.

By Email:
If you provide an email address, you will receive a confirmation email once we receive your form. If you would like to attach files or documents to support your form, you may submit them by replying to the confirmation email and attaching the files to your reply message.

By Mail:
You may mail any attachments or documents to support your form to:

Immigrant and Employee Rights Section (IER)
Civil Rights Division
US Department of Justice
950 Pennsylvania Avenue, NW (4CON)
Washington, DC 20530

By Fax:
You may also fax attachments or documents to support your form to 202-616-5509.

Full Name: *

Street or Mailing Address: *

APT:

City: *

State: *

Zip Code: *

Telephone:

(Home)

(Cell)

E-mail:

Best time to contact (if not represented):

Would you like us to communicate with the Injured Party in another language? YesNo

Preferred language:

What is the Injured Party’s country of birth? *

What is the Injured Party’s national origin (ancestry)? *

What is the Injured Party’s date of birth?
(Month) (Day) (Year)

*

Citizen

National of the United States

Lawful Permanent Resident:

Date residency granted: (Month) (Day) (Year)
Has the Injured Party applied for naturalization? YesNo
Date of application: (Month) (Day) (Year)

Asylee

Refugee

Temporary Resident admitted under § 1160(a) or § 1255(a)

(certain individuals eligible to have their status adjusted based on amendments to the INA in the 1980s)

A #/USCIS # (for all non-citizens):

Admission # (if no A #):

Is the Charging Party the same as the Injured Party? *
Yes, the same. If yes, skip to #8. No

Full Name:

Title:

Entity Name:

Street or mailing address:

APT:

City:

State:

Zip Code:

Telephone:

(Home)

(Cell)

E-mail:

Best time to contact:

Has a charge based on this set of facts been filed with any federal, state, or local governmental agency?
YesNo

If yes:

Full Agency Name:

Agency Street or Mailing Address:

Suite:

City:

State:

Zip Code:

Telephone:

Date Filed:
(Month) (Day) (Year)

File # (if known):

Investigator name (if known):

If IER determines that another government agency would be the appropriate office to investigate your claim, would you like IER to forward your charge to that office? YesNo , contact me before forwarding my charge.

SECTION 9: COMMUNICATIONS WITH IER

Have you previously spoken or communicated with IER prior to filing this charge?
YesNo

If yes,

When?
(Month) (Day) (Year)

If so, how?
Telephone hotlineE-mailOutreach event

If you know, who in IER did you communicate with?

SECTION 10: OPTIONAL INFORMATION

The Injured Party is (check all that apply)

Hispanic or Latino

Asian

Black or African American

White

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Two or more races

SECTION 11: AFFIRMATION

If this charge is being filed by the INJURED PARTY:

As a person alleging that I have been injured by an unfair immigration-related employment practice, I understand that IER may find it necessary to reveal my identity and other information during the conduct of the investigation of my charge, during any hearing or other proceeding as a result of my charge, or in limited circumstances in response to inquiries under the Freedom of Information Act. I give my consent to such disclosure. I affirm that, to the best of my knowledge, the information provided on this form is true.

If this charge is being filed by an AUTHORIZED REPRESENTATIVE of the Injured Party:

I affirm that, to the best of my knowledge, the information provided on this form is true and that I am authorized to file this charge on behalf of the Injured Party. I understand that IER may find it necessary to reveal my identity and/or the Injured Party’s identity during the conduct of the investigation of this charge, during a hearing or other proceeding as a result of this charge, or in limited circumstances in response to inquiries under the Freedom of Information Act. I give my consent to such disclosure.

PRIVACY ACT STATEMENT

The authority for requesting this information from the Injured or Charging Party is contained in 8 U.S.C. § 1324b. The information that the Injured or Charging Party provides will be used principally for investigating and processing the charge of prohibited discrimination; however, the information may also be used for other legitimate purposes, as detailed in the Department of Justice’s Federal Register Notice published in the Federal Register at 68 Fed. Reg. 47611 (August 11, 2003) describing the routine uses of the information obtained by the Civil Rights Division. While completing the form is voluntary, the Injured or Charging Party’s failure to provide the information requested on this form could lead to the charge being dismissed or not being accepted. Knowingly making false statements on this form is punishable under 18 U.S.C. § 1001.

Paperwork Reduction Act Notice

This request is in accordance with the Paperwork Reduction Act of 1995. The information collection is necessary to enable the Department to process and investigate individual charges of discrimination in violation of 8 U.S.C. § 1324b as required by statutory mandate. The use of this collection instrument will facilitate this process by assisting charging parties to identify and provide the information necessary to initiate an investigation.

The estimated average burden associated with this collection is 30 minutes per charging party or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to IER’s Special Policy Counsel, USDOJ-CRT-IER, 950 Pennsylvania Avenue, NW-4CON, Washington, DC 20530.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

OMB Number: 1190-0018
Revised date: October 2024