UI / DE 8498

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Employment Development Department
Discrimination Complaint Form

Please use this form to file a discrimination complaint to the Employment Development Department (EDD). To submit a discrimination complaint, complete this form and send it to the Equal Employment Opportunity (EEO) Office.
By mail:
Employment Development Department
 
Equal Employment Opportunity Office
 
PO Box 826880, MIC 49
 
Sacramento, CA 94280-0001
By fax:
1-916-654-9371
Attn. to:
Equal Employment Opportunity Office

1. Complainant Information:

 
Home Phone:
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Work Phone:
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Cell:
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Name:
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Street Address:
Blank line
City:
Blank line
Email:
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State:
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Zip Code:
Blank line

2. Complainant Contact Information:

When is a convenient time during business hours (8 a.m. to 5 p.m.) to contact you by phone about this complaint?
Day Monday Tuesday Wednesday Thursday Friday
Time          
Phone Number          

3. Contact Information for the person(s) who you claim discriminated against you:

Provide the name of the entity where person(s) work(s):Blank Space
Name of person(s) who discriminated against you:Blank Space
Address of person(s)/entity:Blank Space
City:Blank Space State:Blank Space ZIP Code:Blank Space
Phone:Blank Space
Date of first occurrence:Blank Space
Date of most recent occurrence:Blank Space
DE 8498 Rev. 4 (12-21) (INTRANET)

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4. Tell us about the incident(s):

  • Explain briefly what happened and how you were discriminated against.
  • Provide the date(s) when the incident(s) occurred.
  • Indicate who discriminated against you. Include names and titles, if possible.
  • If other people were treated differently than you, tell us how they were treated differently.
  • Attach any documents that you think may help us better understand your complaint.
 

5. Please list below any person(s) (witnesses) that we may contact for additional information to support or clarify the complaint.

Name Address Phone
     
     
     
     
     
DE 8498 Rev. 4 (12-21) (INTRANET)

SAMPLE, this page for reference only

6. Basis for the discrimination:

 
  • Check the type of discrimination you experienced, such as age, race, color, national origin, disability, etc.
  • If you believe more than one basis was involved, you may check more than one box:

7. Have you previously filed a complaint against this person(s)/entity?

 
If YES, answer the questions below.
a. Was your complaint in writing?
b. On what date did you file the complaint?Blank Space
 
c. Name of office where you filed your complaint:Blank Space
 
 
Address:Blank Space
City:Blank Space State:Blank Space ZIP Code:Blank Space
Phone number:Blank Space
Contact person (if known):Blank Space
d.  Have you been provided a final decision or report?
If you marked “YES”, please attach a copy of the complaint.
 

8. Choosing a personal representative:

  • You may choose to have someone else represent you in dealing with this complaint. It may be a relative, friend, union representative, an attorney, or someone else.
  • If you choose to appoint someone to represent you, all of our communication to you will be routed through your representative.
Do you want to authorize a personal representative to handle this complaint?
If YES, complete the section below. If NO, go to Section 9.
 

AUTHORIZATION OF PERSONAL REPRESENTATIVE

I wish to authorize the individual identified below to act on my behalf as my personal representative in matters such as mediation, settlement conferences, or investigations regarding this complaint.
Name:Blank Space
Mailing Address:Blank Space
City:Blank Space
State:Blank Space
ZIP Code:Blank Space
Phone:Blank Space
Fax:Blank Space
Email:Blank Space
DE 8498 Rev. 4 (12-21) (INTRANET)

SAMPLE, this page for reference only

9. Alternate Dispute Resolution (ADR) also known as mediation.

Notice:
You must indicate if you wish to mediate your case. The EEO Office cannot begin to process your complaint until you have made a selection. Please check YES or NO in the spaces below.
 
  • Mediation is an alternative to having your complaint investigated.
  • Neither party loses anything by mediating.
  • The parties to the complaint review the facts, discuss opinions about the facts, and strive for an agreement that is satisfactory for both.
    • Agreement to mediate is not an omission of guilt by the person(s)/entity that you claim discriminated against you.
    • Mediation is conducted by a trained, qualified, and impartial mediator.
    • Your (or your personal representative) have control to negotiate a satisfactory agreement.
    • Terms of the agreement are signed by the complainant and the person(s)/entity that claim discriminated against you.
    • Agreements are legally binding on both parties.
    • If an agreement is not reached, a formal investigation will start.
    • Failure to keep an agreement will result in a formal investigation.
    • A formal investigation will be opened if retaliation is reported.
 
  • Do you wish to mediate your complaint?
    (Please check only one box)

10. Complainant’s Signature:

Your signature on this form will initiate the processing of this complaint. By signing this form, you are declaring under penalty of perjury that the information included is true and correct to the best of your knowledge or belief.
Signature:Blank Space
Date:Blank Space
EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for services, aids and/or alternate formats need to be made by calling ‎1-916-654-8434 (voice). TTY users, please call the California Relay Service at 711.
DE 8498 Rev. 4 (12-21) (INTRANET)