CCFI Voter Discrimination Complaint Form

COMPLETE THIS FORM ONLY IF YOU VOTED AT YOUR LOCAL POLLING SITE.

This form is patterned after the Department of Justice’s “Discrimination Complaint Form”. Please fill this form out completely. 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.

Your first name

Your last name

Your Street Address

Your Street Address Line 2

Your City

Your State

Your Zip Code

Your Country

Your County

Your Phone Number

Your Email

Polling Site Location

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

Physical location of site

Date discrimination occurred

Time discrimination occurred

How were you discriminated against?

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

Please provide a brief description of what took place

Did you ask for the name(s) of the election official(s) present?

Yes No

If relevant, summarize any interactions with the election officials

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

Yes No

Please use the last 4 digits of your social security numbers as your signature