Charge Form

U.S. Department of Justice
Civil Rights Division

OMB Number 1190-0018

Immigrant and Employee Rights Section (IER)

IER Charge Form

Revised date: 01/XX/17

U.S. immigration law prohibits discrimination on the basis of citizenship status with respect to the hiring, firing, or recruitment
permanent residents who do not apply for naturalization within six months of eligibility). It also prohibits discrimination on the b
are lawfully authorized to work in the United States. The law also prohibits document abuse: when an individual, business, or
completing the Form I-9 because of an individual’s citizenship status or national origin. The law also prohibits retaliation agains
conducted by this office.

Charge Form Instructions:
Who can file a charge: Anyone who alleges he or she is a victim of discrimination or an authorized person on behalf of
the victim. This charge form must be mailed to the address below or faxed to (202) 616-5509 or e-mailed to
[email protected] within 180 days of the alleged date of discrimination. This form should be completed by typing or by
legibly printing the information requested, in any language. If a question is not applicable, it should be left blank.
U.S. Department of Justice
Civil Rights Division
Immigrant and Employee Rights Section - NYA
950 Pennsylvania Avenue, NW
Washington, DC 20530
Questions concerning this charge form can be directed to IER by telephone at (202) 616-5594 or 1-800-255-7688 (toll free),
TTY (202) 616-5525 or TTY 1-800-237-2515 (toll free).
Section 1: Injured Party Contact Information
Name and Address of the Injured Party (the person who claims to have been the victim of discrimination or retaliation):
Full Name:
Street or mailing address:
Apt:

City:

State:

Telephone: (Home)
FAX:

Zip Code:

(Cell)
E-mail:

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

Yes

No

Specify language:
What are the best times to contact the Injured Party by telephone (if not represented)?

IER Charge Form 01/XX/17

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Male

Section 2: Injured Party’s Citizenship or Immigration Status Information
Please provide Injured Party’s citizenship or immigration status or work authorization type:
Citizen
National of the United States
Lawful Permanent Resident: Date residency granted: (Day)
(Month)
(Year)
Date of Application: (Day)
(Month)
(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 1980’s)
None of the above, but is authorized to work: Expiration date: (Day)
(Month)
(Year)

Has the

Please specify:
H-1 H-2 F-1/OPT J-1 B-1 Asylee Applicant
Freely Associated States (FAS) Temporary Protected Status (TPS) (Country):
Other (specify):
Alien #/USCIS # (for all non-citizens):

Admission # (if no alien #):

Section 3: Injured Party’s National Origin and Other Personal Information
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? (Day)

(Month)

(Year)

Section 4: Type of Discrimination Alleged
What type of discrimination is being alleged? Check all that apply:
National Origin Discrimination (The Injured Party was discriminated against with respect to hiring, firing, or
recruitment or referral for a fee because the Injured Party is from a particular country or part of the world, because
of the Injured Party’s ethnicity or accent, or because of limited English ability.)
Citizenship Status Discrimination (The Injured Party was discriminated against with respect to hiring,
firing, or recruitment or referral for a fee because the Injured Party is, or is not, a U.S. citizen, or based on the
Injured Party’s immigration status.)
Retaliation for Asserting Rights Protected Under 8 U.S.C. § 1324b (The Injured Party filed a charge
of discrimination, complained about discrimination, participated in the investigation or case of another individual’s
discrimination claim, or otherwise asserted a right under the anti-discrimination provision, and, as a result, the Injured
Party was retaliated against, intimidated, threatened, or coerced.)
Unfair Documentary Practices (The individual, business or organization refused to accept a valid document, specified
the documentation the Injured Party could show, or demanded more or different documents than are required for
completing the Employment Eligibility Verification (Form I-9 or E-Verify) because of the Injured Party’s
citizenship status or national origin.)

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Section 5: Employer Information
Who committed the alleged discriminatory act?
Company (Employer) name:
Street or mailing address:
Suite:

City:

State:

Zip Code:

Telephone:
If you know, does the Company operate under any other names?

Yes

No

If yes, under what other name(s)?
Number of Employees the Company or Employer employs:
Fewer than 4

4-14

15 or more

Don’t know/Unable to estimate

Section 6: Date and Place the Discrimination Occurred and the Specifics of the Discrimination Alleged
When did the discrimination occur? (Day)

(Month)

(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, la
retaliated against, or other, and describe what happened in detail. (Attach additional sheets if needed. If the Injured Party has any
send copies of documents, not originals.)

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Section 7: Charges Filed with Other Federal or State Agencies Based on the Same Facts
Has a charge based on this set of facts been filed with any federal, state, or local governmental agency?

No

Yes

If yes: Full Agency Name:
Agency Street or mailing address:
Suite:

City:

State:

Zip Code:

Telephone:
Date Filed: (Day)

(Month)

File No. (if known):

(Year)

Investigator name (if known):

Section 8: Charging Party Contact Information (Injured Party or person filing charge on the Injured Party’s
behalf)

Street
or Mailing
Address:
Is the Charging
Party
the same as the Injured Party?
If no, are you (check one):

Male

Yes, the same. If yes, skip to #9.

No

Female

Full Name:

Title:

Entity Name:
Street or mailing address:
Apt:

City:

State:

Zip Code:

FAX:

Telephone:

E-mail:

What are the best times to contact the Charging Party?

Section 9: Communications with IER
Have you previously spoken or communicated with IER prior to filing this charge?
If so, when? (Day)
If so, how?

Telephone hotline

(Month)
E-mail

Yes

No

(Year)

Outreach event

If you know, what is the name of the IER representative you spoke to or communicated with?

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Section10: Affirmation and Signature of Charging Party
If this charge is being filed by the INJURED PARTY:
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 fi
my charge, or in limited circumstances in response to inquiries under the Freedom of Information Act. I give my consent. I affirm
_____________________________________________________
(Signature of Injured Party)

Date:

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 charg
hearing or other proceeding as a result of this charge, or in limited circumstances in response to inquiries under the Freedom of In
Print Representative Name:
Date:
(Signature of Authorized Representative)

Section 11: Optional Information
How did you hear of IER? (check all that apply)
Internet

IER Outreach

State or Local Agency

E-Verify

SSA No Match

I-9 Form or Employer Handbook

Poster/Brochure

United States Citizenship and Immigration Services (USCIS)

Union/Community Advocacy Group

Friend/Relative

Other (specify):

The Injured Party is: (check all that apply):
Hispanic or Latino

Asian

Black or African American

American Indian or Alaska Native

White

Native Hawaiian or Other Pacific Islander

Two or more races

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. 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.
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TV

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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-NYA, 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.

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