Welcome to

Independent Living, Inc.

Promoting Choice, Self-determination and Total Participation

Serving the Mid-Hudson Region Since 1987

Voting 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. For any questions contact Independent Living’s System Advocate (Susan Stockburger) at (845) 565-1162 Ext 237  or call: New York State Independent Living Council (NYSILC) toll free hotline # (888) 469-7452.

I. Contact Information

1.  Your name:     _______________                                                           

2. Address:                                        ____________                                   

3.  County:                                    _______    

4. Telephone number:                                  

5. Email address:                                ____

 II. Polling site location

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

    ___________                                                                                                             

2.  Physical location of site: 

III. Documentation of Possible Voting Rights Discrimination

1.  Date and time the alleged incident of discrimination occurred: 

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

            a. Polling site physically inaccessible, I couldn’t get in

             b. Machine inaccessible, I couldn’t vote privately &  independently.

            c. Ballot inaccessible.  I couldn’t vote privately & independently.

            d. Other form of discrimination. 

3.     Please provide a brief description of what took place.  Use the space on the back of the form if necessary.   

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

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

                                    ______________________________                       

__                                                                                                                      

IV. Conclusion

 1. Would you be interested in discussing the possibility of participating in a class action lawsuit as a result of the possible discrimination you may have suffered?   YES                              NO______________

2.  Signature:                                                                 3. Date:                                   

Please return the completed complaint form to:           

Independent Living, Inc., Attn: Systems Advocate, 5 Washington Terrace, Newburgh, NY  12550 or  Fax:  845-565-0567

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Last modified: October 07, 2008       

Copyright © 2007 Independent Living, Inc.