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Fair Housing Complaint Form

Instructions: Read this form carefully. Try to answer all the questions. If you do not know the answer or a question does not apply to you, leave the space blank. You have one year from the date of the alleged discrimination to file a complaint. Your form should be signed and dated.

Your Contact Information (1/4)

Other Contact Information (2/4)

Who else can we call if we cannot reach you?

What happened to you? (3/4)

What happened to you? (4/4)

Who do you believe discriminated against you? For example: was it a landlord, owner, bank, real estate agent, broker, company, or organization? Identify who you believe discriminated against you.
Where did the alleged act of discrimination occur? For example: Was it at a rental unit? Single family home? Public or Assisted Housing? A Mobile Home? Did it occur at a bank or other lending institution? Provide Address.
When did the last act of discrimination occur?
Is the alleged discrimination continuing or ongoing?

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