(Please submit your completed form to the office of the City Manager, PO Box 1988, Washington, NC 27889 – You will be contacted by a representative of the HRC.)

Name of Complainant ______________________________________________________

Address (Physical and Mailing) _______________________________________________

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Phone Numbers _____________________ (Business) ______________________ (home)

Persons involved in Complaint (both sides) ______________________________________

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Type of Complaint
_____ Employment
_____ Housing
_____ Public Accommodations
_____ Other (please specify) _________________________________________________

Facts (Who, What, Where, When, How, Why) (Please be as specific as possible. Submit an attachment if needed.)

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Questions? Call the Washington City Manager at 975-9319.