Fair Housing Complaint Intake Form

This field is for validation purposes and should be left unchanged.

I am a…*

Your First and Last Name*

Your Race*

American Indian or Alaska Native

Asian

Black or African-American

Native Hawaiian or Pacific Islander

White

Are you Hispanic or Latino/Latina?*

Yes

Client's Race*

American Indian or Alaska Native

Asian

Black or African-American

Native Hawaiian or Pacific Islander

White

Is client Hispanic or Latino/Latina?*

Yes

Your Gender*

Female

Male

Transgender

Non-Binary/Other Gender

Client's Gender*

Female

Male

Transgender

Non-Binary/Other Gender

Your Age*

Client's Age*

Your Yearly Household Income (including all adults who reside with you)*

Client's Yearly Household Income (including all adults who reside in the home)*

Monthly Housing Payment (Rent or Mortgage)*

Number of Adults Living in the Home*

Number of Children Living in the Home*

Do you receive a housing subsidy? If yes, indicate which type (HCV, LIHTC property, etc.)*

Does client receive a housing subsidy? If yes, indicate which type (HCV, LIHTC property, etc.)*

Do you have a disability?*

Yes

Does client have a disability?*

Yes

Your Email Address*

Your Phone Number

Preferred Method of Contact*

Phone

No Preference

Client's Email Address*

Client's Phone Number

Type of Fair Housing Complaint*

Race

Gender Identity

Familial Status

Source of Income

National Origin

Sexual Orientation

Disability (Including Emotional Support and Service Animals)

Street Address of the Property You're Contacting Us About*

Street Address Address Line 2 City ZIP Code

County or City*

Name of Landlord/Management Company, Realtor, or Mortgage Company*

Please describe your Fair Housing issue here. Please be as detailed as possible. (5000 character maximum)*

Please re-type your first and last name here. You affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of your knowledge and belief. If you are filling this out on behalf of someone else, you would need to include your own name.*

Which organizations have you contacted about this issue before contacting us?*

How did you hear about us?*

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