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2. Please enter only the minimal information concerning your complaint. Additional details for your complaint will be collected by an investigator as needed in the future.
   
   Your housing discrimination complaint will be reviewed by a fair housing specialist to determine if it alleges acts that might violate the Fair Housing Act. The specialist will contact you for any additional information needed to complete this review. If your complaint involves a possible violation of the Fair Housing Act, the specialist will assist you in filing an official housing discrimination complaint.
4. Enter Your Personal Information
6. First Name*
7. Last Name*
9. Address*
10. Email Address
12. City*
13. State*
14. Zip Code*
16. Daytime Phone Number
17. Evening Phone Number
18. Best Time to Call
    -- Select One --DayEvening
20. Who else can we call if we cannot reach you?
    Contact Number 1
22. First Name*
23. Last Name*
24. Organization
26. Daytime Phone Number*
27. Evening Phone Number
28. Best Time to Call
    -- Select One --DayEvening
30. Contact Number 2
32. First Name
33. Last Name
34. Organization
36. Daytime Phone Number
37. Evening Phone Number
38. Best Time to Call
    -- Select One --DayEvening
40. Enter Complaint Information
42. What happened to you?*
    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. (4000 character limit)
44. Why do you believe you are being discriminated against?
    It is a violation of the law to deny you your housing rights for any of the following factors:
    -Age (over 40)
    -Color
    -Disability
    -Familial status (families with children under 18)
    -National origin
    -Religion
    -Race
    -Sex
    -Veteran status
    
    For example: Were you denied housing because of your race? Were you denied a mortgage loan because of your religion? Or turned down for an apartment because you have children? Were you harassed because you assisted someone in obtaining their fair housing rights? Briefly explain why you think your housing rights were denied because of any the factors listed above. (4000 character limit)
46. Who do you believe discriminated against you?
    Was it a:
    -Landlord
    -Owner
    -Bank
    -Real estate agent
    -Broker
    -Company
    -Organization
48. First Name
49. Last Name
51. Organization
52. Address
54. Where did the alleged act of discrimination occur?
    Provide the address.
    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?
56. Address
57. City
59. State*
60. Zip Code
62. When did the last act of discrimination occur?*
    When did the last act of discrimination occur?
63. Is the alleged discrimination continuous/on-going?

    1. Yes
    2. No
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field