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State of Florida

Florida Commission on Human Relations

An Equal Opportunity Employer ● Affirmative Action Employer

4075 Esplanade Way Room 110 Tallahassee, Florida 32399-7020

(850) 488-7082 / FAX: (850) 487-1007

http://fchr.state.fl.us

United in One Goal: Equal Opportunity and Mutual Respect

CHARGING PARTY: [plfNm]

RESPONDENT: [defNm]

FCHR No. [fchrNo]

EEOC No. [eeocNo]

CHARGING PARTY – Please complete information below, checking only one:

I am aware that the Florida Commission on Human Relations (Commission) protects my right to file a complaint of discrimination. I have been advised that it is unlawful for any person covered by the Florida Civil Rights Act of 1992, the American with Disabilities Act (ADA), the Age Discrimination in Employment Act (ADEA) or Title VII of the Civil Rights Act of 1964 to threaten, intimidate or harass me because I have filed a complaint.

I make the following election:

______(1) I want the Commission to continue processing and investigating my complaint.

______(2) More than 180 days have elapsed since I filed my complaint of discrimination. I plan to file a civil action in a court of competent jurisdiction. I understand that the Commission will dismiss my complaint.

______(3) More than 180 days have elapsed since I filed my complaint of discrimination. I wish to file a Petition for Relief in order to proceed with an administrative hearing. The commission will email a Petition for Relief form to me which must be completed before proceeding to the Division of Administrative Hearings (DOAH).

______(4) I wish to withdraw my complaint of discrimination from the Florida Commission on Human Relations because I no longer wish to pursue this matter or this matter has been resolved.

Signed:	Dated:

COMMISSIONERS
Monica Cepero Fort Lauderdale	Libby Farmer Tallahassee	Mario Garza Lakewood Ranch	Dawn Hanson Tallahassee
Larry Hart Fort Myers	Darrick McGhee, Chair Tallahassee	Kenyetta Mullins Moyé Tallahassee	Vivian Myrtetus Miami
Pamela Payne Jacksonville	Jay Pichard Tallahassee	Angela Primiano, Vice Chair Hollywood

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