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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.

If you need assistance for any other type of housing issue, please fill out our Request Assistance form

Name

First Name

Last Name

Email Address

Subject

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What type of discrimination?

Choose an option from the dropdown

Alternate Contact Name

Alternate Contact Phone

(###)

###

####

Alternate Contact Email

Please describe what happened in as much detail as possible

Address of the property

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Landlord/Property Manager's Name

Landlord/Property Manager's Phone

(###)

###

####

Landlord/Property Manager's Email

Landlord/Property Manager's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

When did this discrimination occur?

YYYY

Is this still happening?

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.

If you need assistance for any other type of housing issue, please fill out our Request Assistance form

Housing opportunities made equal, inc.

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