If you believe you have suffered discrimination in a City facility or program because of race, color, national origin, ancestry, age, disability, sex, sexual orientation or gender identity, veteran's status, or low-income status, please fill out this form completely and click Submit. The form will be sent to the City of Newton's Human Resources Director. If you do not wish to use the online form, you may download and print the form here: Discrimination Complaint Form or contact the HR Department at dperbeck@newtonkansas.com. 

Name:

Name:

Address:

Address:

City, State, Zip:

City, State, Zip:

Phone Number:

Phone Number:

Are you filing this complaint on your own behalf?

 *

Are you filing this complaint on your own behalf?

Yes

No

If not, please supply the name and relationship of the person for whom you are submitting a complaint:

If not, please supply the name and relationship of the person for whom you are submitting a complaint:

Please explain why you have filed for a third party:

Please explain why you have filed for a third party:

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party:

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party:

Yes

No

Description of your complaint:

 *

Description of your complaint:

Have you previously filed a discrimination complaint with the City of Newton?

Have you previously filed a discrimination complaint with the City of Newton?

Yes

No

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

Yes

No

If yes, check all that apply:

If yes, check all that apply:

Federal Agency: If other, type text here.

Federal Court: If other, type text here.

State Agency: If other, type text here.

State Court: If other, type text here.

Local Agency: If other, type text here.

Please provide information for a contact person at the agency/court where the complaint was filed:

Please provide information for a contact person at the agency/court where the complaint was filed:

If you have any questions about the City of Newton's policies and procedures related to discrimination or civil rights violations, please contact Human Resources Director Debra Perbeck at 316-248-3640 or dperbeck@newtonkansas.com.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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