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HRC Complaint Form

  1. HRC Logo Hands

  2. If you feel you have been the victim of illegal discrimination, file a complaint or report a bias incident by filing out the form below with as much detail as possible. 

  3. 1. Complaint(s) Contact Information:
  4. Are you Hispance?*
  5. 2. Respondent(s) Contact Information: (person, landlord, housing provider, company or other entity against whom you are filing this complaint)
  6. Number of Employees Employed by Respondent (if applicable and if known):*
  7. Protected Class(es): (check all reasons you have been discriminated against and specify the class, e.g. race, African American, sex, female)*
  8. Please include beginning and ending dates

  9. Is the Discrimination continuing?*
    • Based upon the foregoing, I/We allege that the Respondent(s) violated the West Norriton Human Relations Ordinance 2018-719 and/or Section 5 of the Pennsylvania Human Relations Act, 43 P.S. 951-963.
    • The West Norriton Human Relations Commission has jurisdiction over this matter pursuant to the West Norriton Human Relations Ordinance 2018-719.
    • I/We request that the Respondent(s) be required to provide all appropriate remedies under these acts with mediation provided by the West Norriton Human Relations Commission.
  11. I hereby verify that the statements above are true and correct to the best of my knowledge, information, and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S.A. 4904, relation to unsworn falsification to authorities.

  12. Please type your name

  13. Leave This Blank:

  14. This field is not part of the form submission.