BUY™	SELL™	SHOP™
Downloaded From www.TextBookDiscrimination.com
SELL YOUR OWN TEMPLATES (help others get the justice that they deserve)
BUY™	SELL™	SHOP™

WHISTLEBLOWER ACT RETALIATION
CHARGE OF DISCRIMINATION

A. PERSONAL INFORMATION	FCHR No.
Name	Email Address	Date of Birth
[plfNm]	[eml]	[dob]
Mailing Address	Home Telephone Number (area code)
[addy]	[phn]
City, State, and Zip Code	Work (if possible to call you there)
[city]	[phnWk]
B. LIST THE STATE AGENCY OR INDEPENDENT CONTRACTOR THAT DISCRIMINATED AGAINST YOU
Name	Contact Person	Telephone Number
[defNm]	[defCntct]	[phnDef]
Street Address	City, State, and Zip Code	County
[addyDef]	[cityDef]	[couDef]
C. CAUSE OF DISCRIMINATION BASED ON – Check Appropriate Box(es)	DATE MOST RECENT DISCRIMINATION TOOK PLACE (month, day, year)
RETALIATION	[dtEnd]
D. DISCRIMINATION STATEMENT
I REQUEST TO BE AFFORDED FULL RELIEF TO WHICH I AM ENTITLED TO UNDER THE LAWS).
E. VERIFICATION. Under penalties of perjury, I declare that I have read the foregoing complaint of discrimination, and that the facts stated in it are true. I will advise the agency if I change my address or telephone number and I will cooperate fully with them in the processing of my charge in accordance with their procedures.
4/19/2024
SIGNATURE OF COMPLAINANT	DATE

BUY™	SELL™	SHOP™
Downloaded From www.TextBookDiscrimination.com
SELL YOUR OWN TEMPLATES (help others get the justice that they deserve)
BUY™	SELL™	SHOP™