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Fair Housing Program

Housing Discrimination Form


Please fill out this form which will be reviewed by the Fair Housing Program staff.  We will contact you by phone as soon as possible.  Items marked with an * are required.

Please print out a copy of this form for your files.

1.
First Name*:  
M.I.:  
Last Name*:  
Address*:  
City*:  
State*:  
Zip Code*:  

Home or Contact Phone Number*:

  
2.
Name of person(s) and/or Organization complaint is against*:  
City*:  
Address*:  
State*:  
Zip Code*:  
Home or Business Phone Number*:  
3.   The above person is (check one - required):
 Agent  Builder  Broker  Manager or Superintendent  Owner  Loan Officer  Sales person  Other
4.  The above person (check if applicable): 
     refused to sell, rent or negotiate with me,  
     refused to  make an offer to sell or rent 
     falsely deny housing availability
     dispute on availability/use of property
     set discriminatory terms or conditions
     discriminatory services made available
     dispute in renter/buyer qualifications
     dispute in financing or appraising
     blockbusting
     illegal steering
     illegal advertising or solicitation
     harassment, intimidation or threats to keep you from full benefits of the law
     statement of intent, policy or practice of discrimination
5.  I believe I have been discriminated against on the basis of (check if applicable):
Race or Color     National Origin     Sex     Religion     Age
Disability Status   Sexual Orientation    
6.  The kind of property involved in this complaint is:
7.  The owner/agent does  does not live on the property.
8.  The property is being: rented  sold.
9.  The address of the property is:

Address:

City:

State:

 Zip Code:

10.  When did the act(s) checked in item 4 occur? (Include the most recent date if several dates are involved.) 
                       

11.  Summarize in your own words what occurred:
By submitting this information, I declare the above information and statements are true and correct to the best of my knowledge and belief.  I will sign a copy of this submitted information when I meet with a Fair Housing Representative.

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