1. First Name:
2. Last Name:
3. Address:
4. Home Phone:
5. Business Phone:
6. Email:
7. Date of Problem:

1. First Name:
2. Middle Initial:
3. Last Name:
4. Address:
5. City, State:
6. Check the applicable box or boxes which describe(s) the party named above

Builder

Owner

Broker

Salesperson

Superintendent or Manager

Bank or Other Lender

Insurance Agent

Other

7. If Other:

If you named an individual above who appeared to be acting for a company in this case, write the name and address of the company in this space:

1. Name:
2. Address:
3. Name and identify others you believe violated the law in this case:
4. 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 brokers 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

5. If Other, please explain:

1. Check all that apply:
2. Race or Color:

Black

White

Other

3. Religion:
4. Sex:

Male

Female

5. Handicap:

Physical

Mental

6. Familial Status:

Presence of children under 18 in the family

Pregnant female

7. National Origin:

Hispanic

Pacific Islander Native

American Indian

Asian or or Alaskan

Other

8. If Other:

1. 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

2. Did or does the owner live there?

Yes

No

Not Sure

3. Is the house or property:

Being sold or

Being rented

Not Sure

What is the address of the house or property?

1. Street, city, county, state and zip code

Summarize in your own words what happened. Please include names, dates and the times, if you can.

I hereby swear that that I have read this complaint and it is true and correct to the best of my knowledge.
(By entering your full name in the field below, 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.)

1. Signature: