ACLU of Arkansas Complaint Form

904 W. Second Street, Suite One – Little Rock, AR 72201

Please mail this form to the above address – you will receive a written or oral response usually within one
month. There is no guarantee the ACLU will take your case. If there are deadlines, hearing dates, etc.,
please tell us, and take our review period into consideration when deciding what to do.
WE WILL NOT RETURN DOCUMENTS SENT TO US – PLEASE DO NOT SEND ORIGINALS!

The person who feels his or her rights have been violated (Complainant):
NAME:_________________________________ AGE:_____ EMAIL: ___________________________
ADDRESS:__________________________________________________________________________
CITY, STATE, ZIP:____________________________________________________________________
HOME PHONE:____________________________WORK PHONE:______________________________
Have you hired an attorney? (Circle one) YES NO
ATTORNEY’S NAME:_________________________________________________________________
ATTORNEY’S ADDRESS:______________________________________________________________
ATTORNEY’S PHONE NUMBER:________________________________________________________

The person making this complaint if other than the Complainant (above):
NAME:_________________________________ AGE:_____ EMAIL: ___________________________
RELATION TO CLIENT:________________________________________________________________
HOME PHONE:____________________________WORK PHONE:______________________________
The person or agency you want to complain against:
NAME:______________________________________________________________________________
TITLE, PHONE NUMBER:_______________________________________________________________
ADDITIONAL NAME:___________________________________________________________________
TITLE, PHONE NUMBER:_______________________________________________________________
PRIVATE AGENCY:___________________________________________________________________
GOVERNMENT AGENCY:______________________________________________________________
ADDRESS:__________________________________________________________________________
CITY, STATE, ZIP:____________________________________________________________________
DATE OF THE ACTION WHICH IS THE REASON FOR YOUR COMPLAINT:_____________________
May we contact this person/agency? (Circle one) YES NO
May we use your story and/or name in our public education and advocacy work? (Circle
one) YES without name YES with name NO
Is this a new request or a follow up to a previous request? (Circle one) NEW FOLLOW-UP
(PLEASE PROVIDE DESCRIPTION OF PROBLEM ON BACK)
DESCRIPTION OF PROBLEM: (Attach additional pages of explanation if needed)
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What would you like for the ACLU to do for you?

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