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*1. 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.

2. 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: - race - color - religion - sex - national origin - familial status (families with children under 18) - disability.

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.

3. Who do you believe discriminated against you? Was it a landlord, owner, bank, real estate agent, broker, company, or organization?



*5. When did the last act of discrimination occur? Enter the date:

Is the alleged discrimination continuous or on going?
 Yes No

Please upload any files, pictures, documents, ect. that would clarify discrimination in your allegation.