2. 

3. 1000 SW Jackson St.,
   Suite 560
   Topeka, KS 66612-1368

5. Civil Rights Complaint 

7. Your First Name
8. Your Last Name
10. Home Phone Number (include area code)
11. Work Phone (include area code)
13. Street Address
14. City
16. State
17. Zip Code
18. Email Address (if available)

20. Are you filing this complaint out for someone else?

22. First Name
23. Last Name

27. Who or what agency or organization do you believe violated these rights?

29. Person/ Agency / Organization
31. Street Address
32. City
34. State
35. Zip Code
36. Phone Number (include area code)

38. When do you believe the civil rights violation occurred?

40. List Date(s)

42. Briefly describe what happened. How and why do you believe your (or someone else’s) civil rights were violated, or the privacy rule otherwise was violated? Please be as specific as possible.

44. Provide your response below.
46. Attach additional documentation as needed
50. Please sign and date this complaint. You do not need to sign if submitting this form electronically because electronic submission represents your signature.
52. Signature
53. Date

    (mm/dd/yyyy)

55. KC-6501
    04-18

Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field