File a Complaint with the HRC

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   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. 

5. 1. Complaint(s) Contact Information:
7. Name*
9. Filing of behalf of:
11. Address1*
13. Address2
15. City*
16. State*
17. Zip*
19. Telephone Number*
20. Cell Phone Number*
22. Email Address*
24. Date of Birth*
25. Gender Preference*
27. Race*
28. Are you Hispance?*

    1. Yes
    2. No
30. 2. Respondent(s) Contact Information: (person, landlord, housing provider, company or other entity against whom you are filing this complaint)
32. Name*
34. Address1*
36. Address2
38. City*
39. State*
40. Zip*
42. Telephone Number*
44. Number of Employees Employed by Respondent (if applicable and if known):*

    1. Fewer than 4
    2. 4 to 14
    3. 15 to 20
    4. 20 +
    5. Unknown
46. Protected Class(es): (check all reasons you have been discriminated against and specify the class, e.g. race, African American, sex, female)*

    1. Race
    2. Ancestry
    3. Religion
    4. Gender

    1. LBGTQ+
    2. National Origin
    3. Age
    4. Disability

    1. Use of Service Animal
    2. Retaliation for prior complaint
    3. Other
47. If other, please specify:
49. Dates of Discrimination*

    Please include beginning and ending dates

51. Is the Discrimination continuing?*

    1. Yes
    2. No
53. • 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.
55. VERIFICATION

57. 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.

59. Signature*

    Please type your name

60. Date:*
    Date:

    Date:
62. Describe the discriminatory conduct, with specificity, and explain why you feel you were discriminated against because of your protected class. You made upload any documentation, if needed.*
64. Document Upload
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field