Elkhart Fair Housing Complaint Form

Fair Housing Complaint Form

Fields marked with an * are required

Your Name *

Email *

Your Address *

City *

States *

Zip *

Best time to call *

Your Daytime Phone No. Copy *

Evening Phone No.

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Who Else can we call if we cannot reach you?

Contact's Name

Best time to call

Contact Daytime Phone No.

Contact Evening Phone No.

Contact's Name

Contact Daytime Phone No.

Best time to call

Contact Evening Phone No.

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How were you discriminated against? *

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Why do you think you are a victim of housing discrimination? *

Is it because of your: 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? Briefly explain why you think your housing rights were denied and circle the factor(s) listed above that you believe apply.

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Who do you believe discriminated against you? *

Their Address *

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Where did the alleged act of discrimination occur? *

City *

States *

Zip *

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When did the last act of discrimination occur? * *

Is the alleged discrimination continuing or ongoing? *

Yes
No

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Signature *

Date *