1) Why were you discriminated against?
(Example: Refused opportunity to rent or buy a house, a loan, etc.)
2) Why do you think you are a victim of housing discrimination?
(Example: Is it because of your race, color, religion, sex, religion, family status (families with children under 18), disability?)
3) Who do you believe discriminated against you?
(Example: Landlord, owner, bank, real estate agent/broker, company or organization)
4) Where did the alleged act of discrimination occur?
(Example: A rental unit, single family home, public or assisted housing, a mobile home, a bank or other financial institution (note each one). State briefly what happened below.)
5) When did the act of discrimination occur?
First Name:
Last Name:
Address:
Address 2:
City:
State:
Zip:
Email:
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