Please fill out and submit this form if you have experienced housing discrimination. Please include as much information as you can so we know how to help you.

Name *
Name
Date *
Date
Address *
Address
Phone *
Phone
Alternate Contact Phone
Alternate Contact Phone
Address of the property *
Address of the property
Landlord/Property Manager's Phone
Landlord/Property Manager's Phone
Landlord/Property Manager's Address
Landlord/Property Manager's Address
When did this discrimination occur?
When did this discrimination occur?