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Housing Discrimination Complaint Form

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1. Complainant(s) (Your name, address, and phone number):
Name: (First, Middle, Last)
Name of Person to Contact if you cannot be reached:
Work Phone:
Home Phone:
Telephone Number:
Address:
2. List other persons whom were affected by what you believe to be discriminatory acts (other adults, visitors and/or children). Include their name(s) and date(s) of birth.
Name:
Date of Birth:
Name:
Date of Birth:
3. I (We) believe the following is has occured and is about to occur:
A. Refusal to sell, rent, or negotiate; otherwise make unavailable.
B. Discriminatory terms, conditions, or priveleges of sale or rental of a dwelling, or in the provisin of services or facilities.
C: Discriminatory statement, notice, or advertisement with respect to the sale or rental of a dwelling that indicates a preference or limitation.
D: False denial of unavailability.
E. Blockbusting activity.
F: Refusal to allow reasonable modification of premises.
G: Refusal to make reasonable accomodation.
H: Failure to meet design and construction requirements.
I: Discrimination in residential real estate-related transaction and/or lending discrimination.
J: Discrimination in membership or participation in service or organization or facility relating to selling or renting dwellings.
K: Coercion, intimidation, threats, or interference.
4. I believe I was discrimated against because of my:
A) Race:
RaceAfrican American
Hispanic
Asian
Caucasian
Other race:
B) National Origin:
Country:
C) Familial Status:
Children under 18
Pregnant Female
D) Gender:
GenderMale
Female
E) Color:
F) Disability:
Physical
Mental
G) Religion:
5. Adress and location of the property in question. (or if no property is involved, the city and state where the discrimination occurred:
6. Respondent(s) (State who you feel discriminated against you, including the name of the apartment complex, management company, realty company or financial institution, if applicable.
Name:
Title:
Phone Number:
Address:
Name:
Title:
Phone Number:
Address:
7. Please provide a statement (including dates) regarding what occured to make you feel discriminated against.
8. The most recent date you believe the discrimination occured is:
Is this a continuing act?Yes
No
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