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Fill out Complaint Form below and press "Submit" to complete the process.

Complainant Information

* indicates required information

Last Name*
First Name*
Address*
City* State* Zip Code*
Daytime Phone

Example: (ex. 816-555-0101)
Evening Phone*

Example: (ex. 816-555-0101)
Email*
Cell Phone

Example: (ex. 816-555-0101)

My Complaint is Against the following:

* indicates required information

Agency*
Last Name
First Name
Address
City State Zip Code
Daytime Phone

Example: (ex. 816-555-0101)
Evening Phone

Example: (ex. 816-555-0101)
Date of Situation giving rise to your complaint

ex. 05/06/2006
May we contact this person?
Yes No
Witnesses or persons with information regarding your complaint
Have you filed a complaint with any other agencies?
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Name of Agencies
Address of Agencies
City State Zip Code
Are you represented by an attorney in the matter?
Yes No
If so, please provide the following information on the attorney. (continue form)

Attorney Information

Provide this information only if you have a lawyer.

Last Name*
First Name*
Address*
City* State* Zip Code*
Daytime Phone

Example: (ex. 816-555-0101)
Fax

Example: (ex. 816-555-0101)
Cell Phone

Example: (ex. 816-555-0101)
Email*

Filed Lawsuits

Has a criminal or civic lawsuit been filed against you or on your behalf?
Yes No
If so, please provide the following. If not, skip to the Submit button.
Case Title
Case number
Date of Filing
Court with Jurisdiction
Judge
Opposing Counsel
Current Status of the Case
Complaint Description - please provide below a brief description of your complaint *

I understand that, by receiving this complaint, the ACLU of Kansas and Western Missouri (hereafter “the ACLU”) is not agreeing to represent me in any currently pending or future lawsuit or legal proceeding of any kind. Moreover, I understand and agree that the ACLU is not responsible for ensuring that any statute of limitations requirements are met in my case or that any court deadlines are met in any currently pending case or other legal proceeding I may have. I further understand that the ACLU will not be representing me unless and until both a representative of the ACLU and I have signed a written Client Retainer Agreement prepared by a lawyer affiliated with the ACLU. Until such an Agreement has been signed, the ACLU will only be assessing and investigating whether or not it can provide me with representation or other assistance.

I hereby authorize the ACLU to use the information I have provided to the ACLU as necessary to determine whether it will offer me legal or other assistance. I specifically authorize the ACLU to use my name in its investigation of this complaint, including in contacts with the government or other entity about which I have complained.

In addition, after the conclusion of the investigation, I grant permission to the ACLU to transfer to the ACLU archives (currently housed at the Western Missouri Historical Manuscripts Collection on the campus of the University of Missouri at Kansas City) my entire ACLU file. However, the following materials will be protected from public disclosure: (1) private medical records of the client or other individuals involved in the complaint; (2) private financial records (including social security numbers) of the client or other individuals involved in the complaint; and (3) information about the client or other individuals involved in the complaint that would cause extreme embarrassment or humiliation if disclosed to the public. By signing this complaint form, I specifically transfer any property right that I have in my complaint file to the ACLU, the ACLU archives, and the Western Missouri Historical Manuscripts Collection.

Yes