Name

Address

City, State, Zip

Day Time Phone

Evening Phone

Best Number & Time to be reached

E-mail Address

How were you discriminated against? (For example: were you refused the opportunity to rent a home? Denied a loan? )




How were you discriminated against? 
Refused the opportunity to rent a home? 
Denied a loan? 
Other

Please Briefly Explain What Happened:

Why do you think you are a victim of housing discrimination? (For example: were you turned down for an apartment because you have children? Were you denied a loan because of your religion?)

Race
National Origin
Religion
Color
Disability
Family Status
Gender  

Briefly explain why you think your housing rights were denied based on the answer you checked above.

Who do you think discriminated against you? (For example, was is a landlord, owner, banker etc.)

Please identify the person (s) (by name if possible, if you do not know the person’s name, please give a description) who you think discriminated against you.

When did the last act of discrimination occur?  Was the discrimination ongoing?

Please give the date of the last act of discrimination.

A Housing Center staff person will contact you within a week after receiving your complaint form.