Legal Panel Intake Form
Please complete the following fields:
E-Mail:*
Name:*
Home Phone:*
Work Phone:*
Cell/Other:*
Please provide a specific description of the facts relating to your claim including,
where applicable, all relevant dates, times and places:
Type of Violation:

 
Please set forth the identities and contact information for all relevant witnesses to the alleged violation.:
Please describe the nature of the assistance sought and the remedy desired from the ACLU.:
Please list the names and contact information for any attorneys that have assisted you in the past.:
Please provide the case numbers for any civil, administrative or criminal proceedings involved in this matter.:
Please describe the status of the above cases.
I understand that by accepting this complaint, the ACLU is not undertaking legal representation of me, and that the ACLU is not responsible for ensuring that any statute of limitations requirement is met in my case. I hereby authorize the ACLU to use this information in any manner that it deems necessary.

Note: The ACLU Central Chapter only considers cases arising from the Central Florida area. If your case involves another geographical area, please contact the appropriate local chapter or http://www.aclu.org/. If you’re not sure what to do, submit your complaint here and we’ll direct it to the correct Chapter.