Name/Nombre Address Address/Dirección City/Ciudad State/Estado - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code/Código postal Phone/Teléfono Email/Correo electrónico Basis of complaint (Select all that apply)/Bases de la queja (Seleccione todas las que apliquen) Race Color National Origin Sex/Gender Age Disability Retaliation Other Are you a Department of Revenue (DOR) employee?/¿Es usted un empleado del Department of Revenue (DOR)? - Select -YesNo Is this complaint against DOR and/or a DOR employee?/¿Es esta queja contra DOR y / o un empleado de DOR? - Select -YesNo Who discriminated against you?/¿Quién lo discriminó? How were you discriminated against?/¿Cómo fue discriminado? Where did the discrimination occur?/¿Dónde ocurrió la discriminación? Dates and times discrimination occurred?/Las fechas y horas se produjo la discriminación? Name(s) of witness (if applicable)/Nombre(s) del testigo (si es aplicable) Title/organization of witness(s) (if applicable)/Título / organización de los testigos (si es aplicable) Phone number of witness (if applicable)/Número de teléfono del testigo (si es aplicable) How would you like to see this situation resolved?/¿Cómo le gustaría ver resuelto esta situación? Have you filed your complaint, grievance or lawsuit with any other agency or court?/¿Ha presentado su queja con cualquier otra agencia? - Select -YesNo Do you have an attorney in this matter?/¿Tiene un abogado en este caso? - Select -YesNo Name and contact information of attorney (if applicable)/Nombre y datos de contacto del abogado (si es aplicable) Submit Leave this field blank
