Client Intake Form

Have You Experienced Unfair Housing Discrimination?

The Fair Housing Partnership can help! Our organization's roles as a fair housing advocate and enforcer of fair housing laws go hand in hand. Federal, state, and local laws and regulations prohibit discrimination in housing or housing related services based on the following protected classes:

 

Race, Color, Sex, Religion, Age, Disability,

National Origin, Ancestry, Family Status, Sexual Orientation

 

If you feel that you have been a victim of housing discrimination, you can file your fair housing complaint with us online. Please fill out the form below to the best of your knowledge. It may be helpful to review the Fair Housing Laws section of our website. Keep in mind that every case is different, and some sections of this form may not be applicable to your particular situation. Once you submit this form, our staff will review your case to see how we can best assist you. Your personal information will be kept strictly confidential.

 

Remember: To select more than one option, hold down the "Control" (Ctrl) Button.

Fair Housing Partnership Intake Form

*Name
*Address
*City/State
*Zip Code
*Phone #
*Email
*Why are you filing this complaint? (you may select more than one reason)
If "Other," Please Explain:
*Please describe what happened to you. How were you discriminated against? For example: were you refused an opportunity to rent or buy housing? Denied a loan? Denied a reasonable accomodation or modification? State briefly what happened:
*Why do you believe you are being discriminated against? For example: Were you offered different terms and conditions because of your race? Turned down for an apartment because you have children? Are you being harassed because of your protected class?
*When did the last act of discrimination occur? Enter the date (mm/dd/yyyy):
*Is Your Ethnicity Hispanic of Latino/a?Yes No
*Race: Select All that Apply
Familial Status
If You Selected "Children Under 18," How Many are Living in Household?
*Do You Have a Disability?Yes No
If "yes," Please Select All that Apply:
*Do You Require a Support/Service animal?Yes No
*Age
*Date of Birth
*Family Size
*Marital Status
*What is your source of income? (select all that apply)
*Total Monthly Income
*Please Select Your Present Housing Situation (you may select more than one):
*Present Type of Housing
Please Describe if "Other"
If You Selected Apartment Building or Complex, Does it Have Four or More Units?Yes No
*Is the Housing Involved in the Incident of Discrimination the Same as Listed Above?Yes No
Please Select Type of Housing involved in the Incident of Discrimination
Please Fill in the Address/City/State/Zip Code of the Housing Involved in the Incident (If Different Than Above):
Number of Bedrooms
Is the Property Available to Rent or Own?
What is the Monthly Cost of Rent or Mortgage?
How Did You Learn of the Property?
Is it Currently Advertised?Yes No
If "Yes," Where?
Do You Currently Want This Property?Yes No
When Are You Able to Move?
Why Are You Moving?
Please List any Fees Paid to Housing Provider
Did You View the Property?Yes No
Did You Submit an Application?Yes No
Was a Credit Check Performed?Yes No
Was Your Previous Landlord Contacted?Yes No
Any Other Checks/Inquiries? If so, please list.
*Who do you believe discriminated against you? Was it a landlord, owner, bank, real estate agent, broker, company, or organization?
*Against Whom is this Complaint Being filed? (First and Last Name of Housing Provider, if known)
Company (if known)
Position (if known)
Address (if known)
*Phone
*Email/Website
Race of Housing Provider (if known)
Sex of Housing Provider (if known)
*Did you speak with anyone else over the phone, such as an office assistant?Yes No
If so, please fill in their name and position (if known):
*Is There More than One Housing Provider involved?Yes No
If "yes," Please Fill In Additional Name(s) and Contact Information
*Do You have any Witnesses?Yes No
If "yes," Please List their Name(s) and Contact Information
Please List Any Evidence That You May Have (Paperwork, Documents, Bills, etc.)
*How Did You Find The Fair Housing Partnership?
*Have You Filed/Discussed Your Complaint with Another Organization?Yes No
If "yes,"Please List Organization(s):
Click "Submit" to Send This Form to Our Intake Staff. We will be reviewing your case promptly to see how we can best help you.