HOUSING DISCRIMINATION COMPLAINT

	1. NAME OF AGGRIEVED PERSON OR ORGANIZATION
Prefix	Mr. Mrs. Miss Ms.
Name	(last name, first name, middle initial)
Address
City
County
State
Zip
Home Phone:
Business Phone:
	NAME OF CONTACT PERSON
Prefix	Mr. Mrs. Miss Ms.
Name	(last name, first name, middle initial)
Address
City
County
State
Zip
Home Phone:
Business Phone:
Email:	Reguired. Must be completed.
	2. AGAINST WHOM IS THIS COMPLAINT BEING FILED?
Prefix	Mr. Mrs. Miss Ms.
Name	(last name, first name, middle initial)
Address
City
County
State
Zip
Phone Number:
	Check the applicable box or boxes which describe(s) the party named above:
	Builder
	Owner
	Broker
	Salesperson
	Supt. Or Manager
	Bank or Other Lender
	Other
	If you named an individual above who appeared to be acting for a company in this case, check this box and write the name and address of the company in this space:
Name
Address
	Name and identify others (if any) you believe violated the law in this case:
	3. What did the person you are complaining against do? Check all that apply and give the most recent date these act(s) occurred in block No. 6b below.
	Refused to rent, sell, or deal with you
	Discriminated in the conditions or terms of sale, rental occupancy, or in service or facilities
	Falsely denied housing was available
	Advertised in a discriminatory way or made discriminatory statement
	Engaged in blockbusting
	Discriminated in financing
	Discriminated in broker's services
	Intimidated, interfered, or coerced you to keep you from the full benefit of the State and Federal Fair Housing Law
	Other (Explain)
	4. Do you believe that you were discriminated against because of your race, religion, familial status, age, color, marital status, creed, national origin, sex, disability? Check all that apply:
	Race or Color Black White Other
	Religion (specify)
	Sex Male Female
	Disability Physical Mental
	Familial Status Presence of children under 18 in the family Pregnancy or pending custody of a minor.
	Age (specify)
	Creed (specify)
	Marital status
	National Origin (specify)
	5. 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 the owner live there?
	Yes
	No
	Unknown
	Is the house or property:
	Being sold?
	Being rented?
	What is the address of the house or property? (street, city, county, state, & zip code)
	6a. Summarize in your own words what happened. Use this space for a brief and concise statement of facts. The Division of Human Relations will furnish a copy of the complaint to the person or organization against whom the complaint is made.
	6b. When did the act(s) checked in Item 3 occur? (Include the most recent date if several dates are involved)
	7. How did you find out about the Division of Human Relations?

Last Updated: Thursday, 31-Jan-2008 15:55:21 EST