Request for Assessment

If you feel your civil rights have been violated, please complete the form listed below.

You can also click here to download this form as a PDF and email it to us directly at or send it via postal mail to:

LULAC Lane County
1222 E 13th Ave, M40-298
Eugene OR 97403


  • Who is your complaint being filed against?

    Contra quien hace usted esta queja?
  • Nombre/Titulo del Acusado
  • Brief narrative description of incident which the complaining party feels as a violation of his/her Civil Rights.

    Breve narración del incidente el cual UD. siente violo sus Derechos Civiles.
  • PLEASE YOU MUST put your complaint here in a few words.

    POR FAVOR TIENE que ponder su queja aqui en pocas palabras.
  • I attest that this report is a case where it is my belief that my Civil Rights were violated is done with express purpose of giving LULAC Lane County permission to investigate my grievance/complaint. I am represented by legal council at present, I shall notify the LULAC Lane County’s officials assisting me with this issue. I authorize LULAC Lane County to contact any Union or other civil rights entity as it deems necessary.

    Afirmo que este reporte en este caso, donde es mi creencia que mis Derechos Civiles fueron violados es hecho con el propósito de dar permiso a LULAC Lane County de investigar mi queja. Si yo obtengo un abogado les hare saber a los representantes de LULAC Lane County cuales me están ayudando con este caso. Autorizo a LULAC Lane County en contactar cualquier sindicato, u otro grupo de derechos civiles como sea necesario.

    I have written all of the information this report and swear to its accuracy.

    He escrito toda la información en este reporte y verifico la veracidad.