Greater-Waterbury NAACP

The NAACP believes all individuals have equal rights without discrimination based on race. If you have experienced or witnessed an incident of bias, bigotry, hate, or extremism, please fill out our incident intake form below. We will do our best to investigate your situation and respond to you quickly. If this is an emergency, please dial 911.

When you submit your incident through this form, you will be aiding the efforts of NAACP and other advocates to monitor hate incidents across the country. This form does not report directly to law enforcement. If you wish to seek assistance from law enforcement, please contact local law enforcement to report a crime or file a complaint.

By sharing what you experienced or witnessed, you can educate the public, empower others, show service providers where help is needed, and strengthen advocacy efforts for hate crimes response and prevention.

We will not share any of your personal information outside our coalition.

Thank you for your courage in coming forward.

NOTE: The purpose of this form is to gather information for the Legal Redress Committee to consider when determining whether the Greater-Waterbury Branch of the NAACP may be able to assist you with your complaint. Completing this form does not constitute an official complaint with a legal authority, such as filing a lawsuit or a complaint with a governmental agency. Completing this form also DOES NOT establish an attorney - client relationship between the Greater-Waterbury Branch of the NAACP, or the NAACP, and the complainant. The Greater-Waterbury Branch of the NAACP does not engage in the practice of law, and does not provide Legal Advice. Submission of this form DOES NOT mean that the Greater-Waterbury Branch of the NAACP, or the NAACP, has agreed to represent the Complainant in legal matters. Complainants seeking legal advice should contact an attorney in the relevant jurisdiction concerning their particular situation.


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Name:
Address: *
Email: *
Date of incident: *
Where did the incident occur? 
(Please choose the answer that BEST applies)
 *
Describe in detail what happened. 
(consider: relevant dates, relevant documents, the people involved, etc...)
 *
If this incident is associated with a broader systemic issue, please select it here: *
What remedy (or solution) are you seeking? *
How would you describe the motivation behind the incident?
(Please select all the choices that apply)
 *
Required
Were the police called? *
May we contact with you more information? *
Are you a member of the NAACP? *
Are you currently represented by an attorney?  *
May we contact your attorney?
(If YES, please provide the attorney's contact information)
Have you filed a lawsuit, or a complaint with a government agency?
Clear selection
What government agency, if any, have you filed a complaint with?
Would you like to make this report public?

*By selecting "Yes", you give NAACP permission to use your story, without personal information, for publication or use in our materials. We will not share your personal information publicly without your written consent. We may share data confidentially with coalition partners for the purposes of tracking hate incidents, analysis, reporting, and public education.

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Branch Notes *
DISCLAIMER:

I affirm that I have reviewed this complaint form and that it is true to the best of my knowledge.

I hereby sign this release and disclaimer with the understanding that I will hold the NAACP & the GWNAACP harmless for any claim, liability, or lawsuit.

The purpose of this committee is: (1) to review your complaint (2) to discuss possible issues present in your complaint: and (3) to assist with available options.

This committee is an advisory group and does not take legal action.

By signing below, I acknowledge that the NAACP is a voluntary organization, which has in no way agreed to provide me with legal counsel.

I understand that it is my responsibility to seek legal counsel.

(PLEASE SIGN IN THE SPACE PROVIDED BY TYPING OUT YOUR FULL NAME, AND THE DATE THIS FORM IS SUBMITTED)

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