Recreational Boating Safety Grant Program

1.      Complainant's Name 
Address 
City, State, Zip 
Telephone Number (home) 
                          (business)
E-Mail Address 

2.   Person discriminated against (if someone other than complainant)
      Name 
      Address 
      City, State, Zip 
      Telephone Number (home)
                                (business)

3.  What is the name and location of the State or non-profit organization that you believe discriminated against you?

     Name 
     Address 
     City, State, Zip 
     Telephone Number

4.  Which of the following best describes the reason you believe the discrimination took place?  Was it because of your:

        Race, Color and/or National Origin, (specify)  
  Disability, Age or Gender (in education programs) (specify) 

5.  What date did the alleged discrimination take place?  

6.   In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.
     

7.  Do you have any witnesses to verify your allegations?    Yes  No
      If yes,
      Witness Name 
      Address 
      City, State, Zip 
      Telephone     

8.   Have you tried to resolve this complaint through the internal grievance procedure at the accused State or non-profit organization?
      Yes    No
      
       If yes, what is the status of the grievance?
      

       Name and title of the person who is handling the grievance procedure.
       Name 
       Title 
       Telephone Number    

9.    Have you filed this complaint with any other federal, State or local agency, educational institution or non-profit organization; or with any federal or state court?
       Yes   No

If yes, check all that apply:
Federal Agency
Federal Court
State or Local Agency or Court
Educational institution
Non-profit organization

 10.  Please provide information about a contact person at the agency/court where the
complaint was filed.
       Name 
       Address 
       City, State, Zip 
       Telephone Number    

11.   Do you intend to file this complaint with another agency?
       Yes    No

       If yes, when and where do you plan to file the complaint?
       Date 
       Agency 
       Address 
       City, State, Zip Code 
       Telephone Number

12.  Has this complaint been filed with this agency before?
       Yes   No

       If yes, when?  Date 

13.  Have you filed any other complaints with this agency?
       Yes    No

       If yes, when and against who were they filed?
       Date 
       Name   
       Address 
       City, State, Zip 
       Telephone Number

      Give a brief description of the other complaint   
     

      What is the status of the other complaint?
     

14.  Are you represented by an attorney with regard to anything related to this      matter?
       Yes   No

       If yes, please fill in the following:
       Attorney's Name 
       Address 
       City, State, Zip 
       Telephone Number