| (* indicates required field) |
| Please enter your information. |
| First Name: |
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| Last Name: |
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| Address: |
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Home Phone
(ex. ###-###-####): |
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| Business Phone: |
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| Email Address: |
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Date of Problem
(ex. MM/DD/YYYY): |
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| Against whom is this complaint being filed? |
| Name: |
First:
Middle Initial:
Last:
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| Address: |
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| City, State: |
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Check the applicable box or boxes which describe(s) the party named above
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Builder
Owner
Broker
Salesperson
Superintendent or Manager
Bank or Other Lender
Insurance Agent
Other: |
| If you named an individual above who appeared to be acting for a company in this case,
check the box and write the name and address of the company in this space: |
Name:
Address:
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| Name and identify others (if any) you believe violated the law in this case |
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What did the person you are complaining about do? Check all that apply |
Refuse to rent, sell, or deal with you
Discriminate in the conditions or terms of sale, rental occupancy, or in services or facilities
Falsely deny housing was available
Advertise in a discriminatory way
Get you to sell your house for less than you wanted by saying that pricing were falling due to minorities moving in the neighborhood and then reselling the house for more.
Discriminate in financing
Discriminate in broker's services
Intimidated, interfered, or coerced you to keep you from renting or buying the apartment or home of your choice, or in the area of your choice
Other (explain):
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Do you believe that you were discriminated against because of your race, color, religion, sex, disability, the presence of children under 18, or a pregnant female in the family, or your national origin? Check all that apply: |
Race or Color
Black
White
Other
Religion
Please specify:
Sex
Male
Female
Handicap
Physical
Mental
Familial Status
Presence of children under 18 in the family
Pregnant female
National Origin
Hispanic
Pacific Islander Native
American Indian
Asian or or Alaskan
Other (specify):
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What kind of house or property was involved? |
Single-family house
A house or building for 2, 3, or 4 families
A building for 5 families or more
Other, including vacant land held for residential use (explain) |
| Did or does the owner live there? |
Yes
No
Don't Know |
| Is the house or property: |
being sold or
being rented? |
| What is the address of the house or property? (Street, city, county, state and zip code) |
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Summarize in your own words what happened. Please include names, dates and the times, if you can. |
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I hereby swear that that I have read this complaint and it is true and correct to the best of my knowledge.
Signature:
(By entering your full name in the above field, you certify that you are the correct person to fill out the form and that all information presented above is true to the best of your knowledge.) |
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