Please enter your information

First Name

Last Name

Phone Number

E-Mail

Date Problem Occured

Against whom is this complaint being filed?

First Name

Last Name

Check the applicable box or boxes which describe(s) the party named above.

Builder

Owner

Broker

Salesperson

Manager

Bank or Other Lender

Insurance Agent

What did the person above 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 of facilities

Falsely deny housing was available

Advertise in a discriminatory way

Induce you to sell your house for less than you wanted through representations that prices were low due to entry into the neighborhood by people of a certain population and then resold the house for more

Discriminate in financing

Discriminate in broker's 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

Do you believe that you were discriminated against because of your race, color, religion, sex, disability, the presence of children under 18, or a pregnant female in the family, or your national origin? Check all that apply.

Race or Color

Religion

Sex

Disability

Presence of Children or Pregnancy

National Origin

What kind of house or property was involved?

Single family house

A house or building for 2, 3, or 4 families (duplex, triplex, quadplex)

A building for 5 families or more (apartment)

Were you interested in (select one)     Buying the property? or     Renting the property?

What is the address of the property?
(Street, city, county, state, and zip code)

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