Phone________________________ Alternate Phone __________________


City____________________________________ State_________ Zip_________


  1. Summarize the event or the action that you consider a violation of your civil liberties. Include the dates, places, and the names of those who were directly involved. If you need more space please attach any additional pages. If you have supporting documents that would be helpful during the initial review of your complaint, we ask that you provide us copies of those documents (not originals, as we cannot return documents to you) along with this form. Send us copies of only the most relevant documents.






  1. Please explain what you would like the RI ACLU to do for you.




  1. Have you done anything on your own to try and solve the problem (such as filed an appeal, complained to the agency involved, written a public official, or contacted another organization)? If so, please provide the names of individuals or agencies contacted, dates contacted and any outcome.



  1. Have you consulted with an attorney, or are you presently represented by one, regarding this matter?                 Yes, Hired ____ Yes, Consulted____ No____

If so, may we contact him/her for more information?         Yes____ No____

Please provide the name, address and phone number of the attorney:





  1. All complaints received by the RI ACLU are kept confidential. However, in the process of reviewing your complaint, the information you give here may be disclosed to RI ACLU staff, legal advisors, and Board of Directors.

Where we deem it appropriate, do we have your permission to contact authorities or other persons regarding your complaint?                 Yes____ No____

If yes, may we use your name?           Yes____ No____






Please sign and date this Complaint Form:


_________________________________ ___________________________
Your Signature Today’s Date



Please Return By Mail To:
128 Dorrance Street, Suite 220
Providence, RI 02903