n
Lexington Fayette Urban County Government
COMPLAINANT CONSENT/RELEASE FORM
Name of Complainant
E-mail: Address:
Complaint number(s): (if known)
Please read the information below, check the appropriate box, and sign the form.
I have read LFUCG’s Notice of Investigatory Uses of Personal Information. As a
complainant, I understand that in the course of an investigation it may become necessary for
LFUCG to reveal my identity to persons at the organization or institution under investigation. I
am also aware of the obligations of LFUCG to honor requests under the Freedom of
Information Act. I understand that it may be necessary to disclose information, including
personally identifying details that LFUCG has gathered as a part of its investigation of my
complaint. In addition, I understand that as a complainant I am protected by regulations from
intimidation or retaliation for having taken action or participated in action to secure rights
protected by nondiscrimination statues.
CONSENT – I have read and understand the above information and authorize LFUCG to reveal my
identity to persons at the organization or institution under investigation. I hereby authorize
LFUCG to receive material and information about me pertinent to the investigation of my
complaint. I understand that the material and information will be used for authorized civil rights
compliance and enforcement activities. I further understand that I am not required to authorize this
release, and do so voluntarily
CONSENT DENIED – I have read and understand the above information and do not want
LFUCG to reveal my identity to the organization or institution under investigation, or to review, receive
copies of, or discuss material and information about me, pertinent to the investigation of my complaint.
I understand this is likely to impede the investigation of my complaint and may result in the closure of
the investigation.
SIGNATURE DATE
click to sign
signature
click to edit
![]()
