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Housing Discrimination Complaint Form

All fields are required

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 is 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?  
6. Is the alleged discrimination still continuing or occurring?  
First Name:  
Last Name:  
Address 1:  
Address 2: