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Housing Discrimination Complaint Form
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This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Step One
This section is complete
This section is incomplete
2.
Your Information
This section is complete
This section is incomplete
Step One
Please fill in each blank to the best of your ability. If no answer, write N/A.
Full Name
*
Phone Number
*
Street Address
*
City
State
Zip
Email
Continue
Your Information
The following person always knows where to contact me.
Full Name
Phone Number
Street Address
City
State
Zip
Email
Cause of Discrimination
*
Color
Familial Status (Families With Children)
National Origin
Physical or Mental Handicap
Race
Religion
Sex (Gender)
I am
*
Give race, religion, sex, etc., as it specifically applies to your case.
Who do you wish to file your complaint against?
Full Name
Phone Number
Street Address
City
State
Zip
Date of Discriminatory Act
Date of Discriminatory Act
Discrimination of a Continuing Nature
Yes
No
Date Harm Began
Date Harm Began
Briefly describe what happened
*
Occupation of Discriminator
Builder
Owner
Broker
Salesperson
Building Superintendent
Manager
Rental Agent
Bank or Other Loan Agency
Other
Please Specify
If you have named an individual as the discriminator, and you know that he/she was acting for a company matter, fill in the following information.
Company Name
Phone Number
Street Address
City
State
Zip Code
Please provide information for any other person(s) or organization(s) you believe should be charged in this complaint.
Full Name
Phone Number
Street Address
City
State
Zip Code
Kind of House/Property Involved
Building for 5 Families or More (Including Apartments)
House or Building for 2, 3, or 4 Families
Mobile Home
Single Family Home
Other
Specify (Including Vacant Land)
House/Property is For
Sale
Rent
Action Causing Complaint
Directed to all white, integrated, or predominantly black area
Refused rent, sale, or deal
Discriminated in the condition of the terms of sale, rental, or occupancy
Advertised in discriminatory way
Falsely denied housing available
Engaged in panic peddling
Discriminated in financing
Discriminated in broker services
Evicted from premises
Other
Please Specify
What is the name and address of the property involved?
Full Name
Phone Number
Street Address
City
State
Zip Code
List names of any witnesses who have information about this particular problem of his/her own knowledge, not second hand.
Full Name
Phone Number
Street Address
City
State
Zip Code
Full Name
Phone Number
Street Address
City
State
Zip Code
Full Name
Phone Number
Street Address
City
State
Zip Code
List any other person(s) affected because of this problem, and explain how.
Full Name
Phone Number
Street Address
City
State
Zip Code
Age
How
Full Name
Phone Number
Street Address
City
State
Zip Code
Age
How
Full Name
Phone Number
Street Address
City
State
Zip Code
Age
How
Still Interested in This Property
Yes
No
What is Needed to Settle Complaint
I have not commenced any actions, civil or criminal, based upon the grievance set forth above, except for the following:
Please be as complete as possible in answering all of the above questions. The more information you can provide, the better our staff can serve you and the many other persons who have filed complaints. Thank you.
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