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)

Your First Name *Your Last Name *Your Address *City *

State *Zip Code *Best time to call *Your Daytime Phone No. *Evening Phone No. Receive messages and notifications via SMS.

Other Contact Information (2/4)

Who else can we call if we cannot reach you?

Contact 1 Name *Best time to call *Daytime Phone No. *Evening Phone No.Contact 2 Name

Best time to callDaytime Phone No.Evening Phone No.

What happened to you? (3/4)

How were you discriminated against? For example: were you refused an opportunity to rent or buy housing? Denied a loan? Told that housing was not available when in fact it was? Treated differently from others seeking housing?

State briefly what happened.

Why do you think you are a victim of housing discrimination? Is it because of your:

Race, Color, Religion, Sex, National Origin, Familial Status (families with children under 18) or Disability? For example: were you denied housing because of your race? Were you denied a mortgage loan because of your religion? Where you turned down for an apartment because you have children? Briefly explain why you think your housing rights were denied including the above that you believe apply.

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.

Name *Address *

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.

Address *City *State *Zip Code *

When did the last act of discrimination occur?

Enter a Date *

Is the alleged discrimination continuing or ongoing?

YES NO

Signature Date *Your Signature *

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