Please specify if this was before or after December 2011:
______
Before
______
After
Name of person racially profiled: __________________________________________
Approximate Date of incident: ___________________________________________ Phone number: __________________ Email: __________________________ _____ Were you given a citation (ticket)?
Yes
No _
Do you have a copy?_Yes
No_
What are you charged with? ______________________________________________
Were you Handcuffed or Arrested?
Yes
No ______________________
__
Location/address of incident (best estimate): _________________________________
Where you asked about your legal status?
Yes
Were passengers in the car asked about their legal status?
Additional notes:
When form completed please mail to:
Somos America C/O Respect Respeto P.O Box 4066 Phoenix, AZ 85030