Vermont Human Rights Agency Charge of Discrimination (HRC / AG CRU)
Vermont Charge of Discrimination — Statement of Facts
To: [VERMONT HUMAN RIGHTS COMMISSION / VERMONT ATTORNEY GENERAL'S OFFICE]
Official form or intake reference: [________________________________]
Agency case number, if assigned: [________________________________]
I, [FULL LEGAL NAME], state the following facts in support of my complaint of discrimination:
Charging Person and Respondent
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My mailing address is [ADDRESS]. My telephone number is [NUMBER] and my email is [EMAIL]. My preferred contact and accessibility needs are [DETAILS].
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The respondent's exact legal name is [NAME]. Its address and other identifying information are [ADDRESS / FACILITY / EMPLOYER / STATE AGENCY]. The people directly involved are [NAMES, TITLES, AND ROLES].
Claim and Agency Route
- This complaint concerns [SELECT AND KEEP ONE OR MORE FACTUALLY SUPPORTED ROUTES]:
- Employment under 21 V.S.A. § 495: The respondent is [EMPLOYER / EMPLOYMENT AGENCY / LABOR ORGANIZATION]. If an employer, it has [DESCRIBE ONE OR MORE INDIVIDUALS PERFORMING SERVICES IN VERMONT]. I performed services for [DIRECT OR INDIRECT GAIN OR PROFIT]. My asserted § 495(a)(1) characteristic or § 495(a)(8) protected activity is [EXACT BASIS AND FACTS]. The respondent [DESCRIBE HARASSMENT, DISCRIMINATION, OR RETALIATION].
- Public accommodation under 9 V.S.A. § 4502: [FACILITY] offers [GOODS, SERVICES, OR BENEFITS] to the public. The respondent [OWNS, OPERATES, OR ACTED FOR THE OWNER/OPERATOR]. My asserted basis is [EXACT § 4502(a) CHARACTERISTIC / DISABILITY UNDER § 4502(c)]. The respondent denied or limited [SPECIFIC SERVICE, FACILITY, OR BENEFIT].
- Housing under 9 V.S.A. § 4503: The transaction concerns [DWELLING OR OTHER REAL ESTATE, ADDRESS, AND SALE/RENTAL CONTEXT]. My asserted basis is [EXACT § 4503(a) BASIS]. The respondent [IDENTIFY THE SPECIFIC REFUSAL, DIFFERENT TERM, HARASSMENT, ADVERTISEMENT, OR OTHER ACT AND THE RELEVANT SUBDIVISION].
- I selected the [HUMAN RIGHTS COMMISSION / ATTORNEY GENERAL'S OFFICE] because [PUBLIC ACCOMMODATION OR HOUSING / STATE-AGENCY EMPLOYMENT / OTHER EMPLOYMENT] under 9 V.S.A. § 4552. [IF A STATE AGENCY IS THE RESPONDENT, IDENTIFY IT.]
Dated Facts
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The first act I challenge occurred on [DATE] at [PLACE]. [PERSON] did or said [EXACT WORDS OR CONDUCT].
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On [DATE], [PERSON] did or said [EXACT WORDS OR CONDUCT]. Additional dated incidents are [CHRONOLOGY OR ATTACHED PAGE].
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The most recent act I challenge occurred on [DATE]. The facts connecting the respondent's acts to the selected characteristic or activity are [STATEMENTS, SEQUENCE, COMPARISONS, DOCUMENTS, OR OTHER FACTS].
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I reported the matter or requested correction on [DATE] by [METHOD AND RECIPIENT]. The respondent replied or took action on [DATE] by [FACTS]. [REMOVE IF INAPPLICABLE.]
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The result was [EMPLOYMENT LOSS, DENIED SERVICE, HOUSING EFFECT, FINANCIAL LOSS, OR OTHER SPECIFIC HARM]. My requested practical resolution is [SPECIFIC CORRECTION OR RELIEF].
Witnesses and Records
| Witness or record | Contact or custodian | What it shows | Available or attached |
|---|---|---|---|
| [________________] | [________________] | [________________] | [________________] |
| [________________] | [________________] | [________________] | [________________] |
I ask the selected agency to review and investigate these facts under its current complaint procedure. I understand that an HRC complaint must be under oath and is reviewed by Commission staff before it may be accepted for investigation under 9 V.S.A. § 4554(a).
I swear or affirm that the factual statements above are true to the best of my knowledge. Information learned from others is identified as such: [DETAILS OR NONE].
Date: [__/__/____]
Charging person's signature: [________________________________]
Printed name: [________________________________]
State of [__________], County of [__________], ss.
Subscribed and sworn to before me on [__/__/____] by [NAME].
Signature of authorized officer: [________________________________]
Printed name, title, commission expiration, and seal: [________________________________]
Sources
- 9 V.S.A. § 4552: https://legislature.vermont.gov/statutes/section/09/141/04552
- 9 V.S.A. § 4554: https://legislature.vermont.gov/statutes/section/09/141/04554
- 21 V.S.A. § 495: https://legislature.vermont.gov/statutes/section/21/005/00495
- 21 V.S.A. § 495d: https://legislature.vermont.gov/statutes/section/21/005/00495d
- 9 V.S.A. § 4502: https://legislature.vermont.gov/statutes/section/09/139/04502
- 9 V.S.A. § 4503: https://legislature.vermont.gov/statutes/section/09/139/04503
About this template
- Last updated
- September 27, 2026
- Citations checked
- September 27, 2026
- Jurisdiction
- Vermont
- Category
- Civil Rights
Legal authority
- 9 V.S.A. § 4552(b), (c)
- 9 V.S.A. § 4554(a)
- 21 V.S.A. § 495(a)(1), (a)(8)
- 21 V.S.A. § 495d(1), (2)
- 9 V.S.A. § 4502(a), (c)
- 9 V.S.A. § 4503(a)
Civil rights cases address violations of your constitutional or federally protected rights by government officials, employers, landlords, or businesses. Most of these claims come with short deadlines and specific filing requirements. Well-drafted complaints and demand letters identify the right law, name the right parties, and preserve your claims before the clock runs out.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on September 27, 2026.
9 V.S.A. § 4552 (checked September 27, 2026): "The Commission shall also have jurisdiction when the party complained against is a State agency in matters for which the Attorney General would otherwise have jurisdiction under subsection (c) of this section."
9 V.S.A. § 4554 (checked September 27, 2026): "Any person who believes he or she has been subject to unlawful discrimination may file a complaint under oath with the Commission stating the facts concerning the alleged discrimination. Every complaint shall be reviewed by the staff of the Commission. If a complaint states a prima facie case, it may be accepted for investigation."
21 V.S.A. § 495 (checked September 27, 2026): "For any employer, employment agency, or labor organization to harass or discriminate against any individual because of race, color, religion, ancestry, national origin, sex, sexual orientation, gender identity, place of birth, crime victim status, or age or against a qualified individual with a disability."
21 V.S.A. § 495d (checked September 27, 2026): "that has one or more individuals performing services for it within this State."
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