LFUCHRC Housing Intake Form

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.