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University of Iowa Committee on Human Rights policies, 1958-1986

Instructions for Filing a Complaint of Discrimination Page 3

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I further state that the person(s) who committed the discriminatory act is/are ________________________, whose address is: ________________________.

I have (have not) filed my complaint with any other local, state, or federal agency. (If so, with what agency? _______________________)

_______________
Complainant

The University of Iowa )ss:
I, __________________ hereby depose and state that I am the complainant herein; that I have read the foregoing complaint and know the contents thereof; that the information herein is a factual statement to my knowledge.

________________
(Signed)

Subscribed and sworn to before me this ____ day of ____________, 19_____.

_____________________
Notary Public in and for 
Johnson County, Iowa

My commission expires on the __________ day of _______, 19__________.

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-2- I further state that the person(s) who committed the discriminatory act is/are ________________________, whose address is: ________________________. I have (have not) filed my complaint with any other local, state, or federal agency. (If so, with what agency? _______________________) _______________ Complainant The University of Iowa )ss: I, __________________ hereby depose and state that I am the complainant herein; that I have read the foregoing complaint and know the contents thereof; that the information herein is a factual statement to my knowledge. ________________ (Signed) Subscribed and sworn to before me this ____ day of ____________, 19_____. _____________________ Notary Public in and for Johnson County, Iowa My commission expires on the __________ day of _______, 19__________.