VOTER DISCRIMINATION COMPLAINT FORM

This form is patterned after the Department of Justice’s “Discrimination Complaint Form”. Please fill this form out completely. Please print neatly or type. Please contact Chris Zachmeyer at 607-432-8000 or ccfi@ccfi.us or Brad Williams at 518-427-1060 or nysilc@nysilc.org if you have any questions.

Complainant names will be kept confidential and only shared with NYSILC’s work group. Content will be compiled into a comprehensive report. Individuals will have the option to consider involvement in a class action lawsuit. Once a person completes a form for a given polling place, it is important that they follow up on future Primary and Election Days. This will help document a timeline of how long the discrimination lasted and/or when it was remedied.

Name:

Address:

County:

Phone Number: Email:

II. Polling site location

1. Name of site (Ex. Town of Utopia Town Hall)

Physical location of site:

III. Documentation of Voting Rights Discrimination

1. Date and time discrimination occurred:

2. How were you discriminated against? (Check any that apply)

Polling site physically inaccessible, I couldn't get in.

Machine inaccessible, I couldn't vote privately and independently.

Ballot inaccessible, I couldn't vote privately and independently.

Other form of discrimination.

3. Please provide a brief description of what took place.

4. Please provide name(s) of the election official(s) present:

Or

Did not ask for name(s) of election official(s) present.

5. If relevant, summarize any interactions with the election officials:

IV.  Conclusion

Are you interested in discussing the possibility of participating in a class action lawsuit as a result of the discrimination you suffered?