REQUEST ASSISTANCE "*" indicates required fields Complainant Name* First Last Incident Date* MM slash DD slash YYYY If multiple incidences, please explain.Complainant Phone Number*Complainant Email Address* Complainant Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands RJPMC seeks to dismantle systemic oppression within the legal system and eliminate barriers to accessing legal services. As such, RJPMC prioritizes supporting BIPOC survivors of discrimination, bias, and misconduct and/or those who are unable to otherwise access legal services due to income, ability, or other factors. Please fill out the below section to help us ensure we are equitably serving the community.Racial Identity*Gender Identity*Disability (if applicable)Any other identity you would like to include (if applicable)?Are you receiving housing assistance? If yes, explain below.* Yes No Are you receiving any benefits? If yes, explain below.* Yes No Explain housing assistance you receive (answer only if you answered "Yes" above).Explain benefits you receive (answer only if you answered "Yes" above).Description of Assistance Requested: RJPMC provides direct assistance in investigating claims and providing non-legal advocacy. RJPMC places cases for partial and full legal representation with one of our participating law firms or attorneys who have agreed to provide pro bono services or low bono services (with funding provided by RJPMC). Please describe the assistance you are seeking from RJPMC.Do you need assistance by a specific date? If yes, please explain.* Yes No Explanation (required if you answered "Yes" on the previous question).*Description of assistance requested.*Actions Taken Thus Far: Please confirm the actions you have already taken before submitting this complaint.Filed a complaint with any police or governmental agency? If yes, please explain.* Yes No Explanation (required if you answered "Yes" on the previous question).*Contacted or filed a complaint with the applicable personnel office, if employment related? If yes, please explain.* Yes No Explanation (required if you answered "Yes" on the previous question).*Filed a grievance with your union, if applicable? If yes, please explain.* Yes No Explanation (required if you answered "Yes" on the previous question).*Contacted or filed a complaint with the applicable school district, if education related? If yes, please explain.* Yes No Explanation (required if you answered "Yes" on the previous question).*Contacted or filed a complaint with the Office of Civil Rights, if education related? If yes, please explain.* Yes No Explanation (required if you answered "Yes" on the previous question).*Retained an attorney? If yes, please explain.* Yes No Explanation (required if you answered "Yes" on the previous question).*Filed a lawsuit? If yes, please explain.* Yes No Explanation (required if you answered "Yes" on the previous question).*Any Additional Information Please provide any additional information you would like us know:Additional InformationAttestation* Attestation: I am seeking assistance from RJPMC and affirm that the information I have provided in connection with seeking such help is true to the best of my knowledge. I authorize RJPMC to access information, documents, and people relevant to my complaint. Attestation* Disclaimer: I understand that RJPMC does not provide any legal services or legal advice and bears no responsibility for services or advice provided by participating attorneys. By checking this box you are applying your electronic signature. Electronic signature*
