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Civil Rights and Hate Crime Please email the following information to This e-mail address is being protected from spambots. You need JavaScript enabled to view it . You may cut and paste this information into a MS Word document and email as an attachment or fax to 317-204-4499. Your Information: Incident Date: First Name Last Name Home Phone Mobile Phone Work Phone Fax Email Address Gender Street Address City State Zip Ethnic Background Religion Filer name* (If different from above) Please provide a detailed description of the incident below. Include date, time, witnesses, and any evidence of religious discrimination.
Offending Party Information: First Name Last Name Home Phone Work Phone Mobile Phone Fax Gender Title Affiliation Street Address City State Zip |