Housing Intake Form

 Please completely answer the following questions, telling us why you believe that you have been discriminated against in housing.  Please use the TAB key to move through the fields.  Pressing enter will submit the form to the HRC.

Name

First Name Last Name Middle Initial
Address
City
State
Zip Code
Home Phone Number
Work Phone Number
Date of Birth
E-mail address
Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other (Specify)
Ethnicity

Hispanic or Latino

Not Hispanic or Latino

AGAINST WHOM IS THIS COMPLAINT BEING FILED?

Name
Address
City
State
Zip Code
Telephone Number

Check the applicable box that describes the party named above:

Builder Superintendent/Manager Owner
Bank or Other Lender Broker Salesperson
Other (Specify)

If you have named an individual above and that individual appeared to be acting on behalf of a company, please complete the following information:

Company Name
Address
City
State
Zip Code
Telephone Number

Please utilize the space below to indicate identifying information on any additional entities or individuals related to the individual or company you named above and whom you think should be named in this complaint.  (Please indicate the address of the property involved in your complaint).

When did the act(s) occur? (Include the most recent date if several dates are involved)

What did the person you are complaining against do? (Check all that apply)

Refuse to rent, sell or deal with you
Falsely deny housing was available
Advertise in a discriminatory way
Discriminate in the conditions, terms of sale, rental occupancy or in services or facilities
Intimidated, interfered, or coerced you to keep you from the full benefit of the Federal Fair Housing Law
Discriminate in financing
Engage in blockbusting
Discriminate in broker's services
Other (Specify)

Do you believe that the action taken against you was because of: (Check all that apply and specify, where applicable)

Race or Color National Origin
Black Hispanic
White Asian or Pacific Islander
Other (Specify) American Indian
Other (Specify)
Sex Disability
Male Physical
Female Mental
Familial Status (Children under 18 or pregnant female) Religion
Sexual Orientation/Gender Identity

What kind of house or property was involved?

 Single family house

A building for 5 or more families

A house or building for 2, 3 or 4 families

Other, including vacant land held for residential use

Did the owner live there?  Yes                No                Unknown

Is the house or property    Being sold?                            Being rented?

Please summarize in your own words what happened that you believe to be discriminatory.

   

Who took that action?   

What was the reason given?

Please list the names, addresses and telephone numbers for any individuals whom you believe would be able to provide information about the situation that you are complaining:

Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number

Please provide the name of an individual in the local area, who does NOT live with you, who would know how to reach you at any time.  This person must have a telephone number and a street address.

Name
Relationship
Address
City/State/Zip
Telephone Number

By submitting this information, you affirm that the information contained in your response to this Intake Form is true and correct to the best of your knowledge and belief.

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Last modified: 04 Sep 2022