Enter your information.

Name:  Time to Call:  Daytime Phone No: 
Your Address:  Evening Phone No: 
City:  State:  Zip: 

Who else can we call if we can't reach you?

1 Contact's Name:  Daytime Phone No: 
Best time to call:      Evening Phone No:  
2 Contact's Name:  Daytime Phone No: 
Best time to call:      Evening Phone No:  

 Enter complaint information.

  • What happened to you? How were you discriminated against? For example: were you
    refused an opportunity to rent or buy housing? Denied a loan? Told that housing was not
    available when in fact it was? Treated differently from others seeking housing? State briefly
    what happened.
  • Why do you believe you are being discriminated against?
    It is a violation of the law to deny you your housing rights for any of the following factors:
    - race - color - religion - sex - national origin - familial status (families with children under
    18) - disability.

    For example: were you denied housing because of your race? Were you denied a mortgage
    loan because of your religion? Or turned down for an apartment because you have
    children? Were you harassed because you assisted someone in obtaining their fair housing
    rights? Briefly explain why you think your housing rights were denied because of any the
    factors listed above.
  • Who do you believe discriminated against you? Was it a landlord, owner, bank, real
    estate agent, broker, company, or organization?

Name: 

Address: 

  • Where did the alleged act of discrimination occur? Provide the address. For example:
    Was it at a rental unit? Single family home? Public or Assisted Housing? A Mobile
    Home? did it occur at a bank or other lending institution?

    Address: 

    City:              State:      Zip: 

  • When did the last act of discrimination occur? Enter the date:  (mm/dd/yyyy)
    Is the alleged discrimination continuous or on going?  Yes  No