Complainant Information Name * Phone (daytime) * Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Email * Vehicle and Driver Information Provide as much information about the taxicab and driver as you can. Missing information may prevent the Department from identifying the driver and resolving your complaint. Company's name License Plate Taxicab number Driver's license and identification card Driver's name (if known) Trip Information Origin address Origin city Origin state - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Destination address Destination city Destination state - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Stops made en route En route stop address Trip date & Departure Time Taxi: Hailed, Dispatch or App Hailed Dispatched If App: DC Taxi Uber Lyft Other If Other (name) Transport DC: Yes No Total passengers Fare paid to driver Fare receipt (Scan and upload as PDF or word document) (Attach a copy of your receipt if one was provided) Section II Please answer the question below to file a complaint of discrimination with the DC Office of Human Rights: Do you believe you were discriminated against by a driver or company because of one of the protected traits below? Yes No If you answered “Yes†in the above question, which protected traits do you believe were used to allegedly discriminate against you? Age Breast Feeding Color Disability Familial status Family responsibilities Gender identity or expression Genetic information Marital status Matriculation (status as a student) National origin Personal appearance Place of residence or business Political affiliation Race Religion Sex (including pregnancy) Sexual orientation Section III Details about the incident, additional information, comments or concerns, including why you believe it was discrimination-related (if discrimination alleged): Videos/photo of incident (if obtained): Reasonable accommodation or language interpretation (if necessary): Electronic signature (Full Name) Date: CAPTCHA This question is for testing whether you are a human visitor and to prevent automated spam submissions.
