Charge Form - Corrected First Page

I8

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 or referral for a fee of protected individuals: citizens, nationals of the United States, permanent residents,
temporary residents, refugees, and asylees (excluding lawful permanent residents who do not apply for naturalization
within six months of eligibility). It also prohibits discrimination on the basis of national origin (against employers with
four to fourteen employees) with respect to the hiring, firing, or recruitment or referral for a fee of all individuals who are
lawfully authorized to work in the United States. The law also prohibits unfair documentary practices: when an individual,
business, or organization refuses to accept a valid document, specifies the documentation an individual can provide or
demands more or different documents than are required for completing the Form I-9 because of an individual’s citizenship
status or national origin. The law also prohibits retaliation against individuals for asserting their rights protected under the
anti-discrimination provision of the immigration law, or for having participated or assisted in an investigation 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):
Male
Female
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

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

No

I8

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 or referral for a fee of protected individuals: citizens, nationals of the United States, permanent residents,
temporary residents, refugees, and asylees (excluding lawful permanent residents who do not apply for naturalization
within six months of eligibility). It also prohibits discrimination on the basis of national origin (against employers with
four to fourteen employees) with respect to the hiring, firing, or recruitment or referral for a fee of all individuals who are
lawfully authorized to work in the United States. The law also prohibits unfair documentary practices: when an individual,
business, or organization refuses to accept a valid document, specifies the documentation an individual can provide or
demands more or different documents than are required for completing the Form I-9 because of an individual’s citizenship
status or national origin. The law also prohibits retaliation against individuals for asserting their rights protected under the
anti-discrimination provision of the immigration law, or for having participated or assisted in an investigation 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):
Male
Female
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

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

No