Fillable Community Development & Housing (Sussex County Council)

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Community Development & Housing (Sussex County Council)

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U.S.A. forms for Sussex County Council

BROWSE SUSSEX COUNTY COUNCIL (DE) FORMS

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County Administrative Offices
West Complex
22215 Dupont Blvd. | PO Box 589
Georgetown, DE 19947
Phone: (302) 855-7777
Fax: (302) 854-5397
sussexcountyde.gov
Community Development & Housing
HOUSING DISCRIMINATION COMPLAINT
INTAKE FORM
Rev. 09/2018
Evening or Cell Phone:
Evening or Cell Phone:
Against whom is this complaint being filed? (name(s), title of person(s), organization or County department/
division
Do you believe that you were discriminated against because of your race, color, national origin, religion, creed,
sex, marital status, familial status, source of income, age, sexual orientation, handicap/disability, or gender
identity? Check all that apply.
Race or Color (Specify)
Religion (Specify) Sex Age Marital Status
Please print or type.
Name of aggrieved person or organization:
Daytime Phone:
Email Address:
Street Address (city, state, and zip code):
Daytime Phone:
Name of Contact Person:
Black
Other
White
Female
Male
National Origin (Specify)
Creed (Specify) Gender Identity Sexual Orientation
Familial Status
Presence of children under 18 in the family
Presence or pending custody of a minor
Handicap/Disability Source of Income
Physical
Mental
What did the person you are complaining against do? Check all that apply.
Made housing unavailable to you because of your race, color, national origin, religion, creed, sex, marital
status, familial status, source of income, age, sexual orientation, handicap/disability, or gender identity
Discriminated in the terms, conditions, or privileges of the sale, rental, or rehabilitation of a dwelling
Discriminated in the provision of services or facilities in connection with the sale, rental, or rehabilitation of
a dwelling
Engaged in discriminatory advertising or statements with respect to a housing transaction or project
Interfered with the funding, development, or construction of affordable housing
Enforced a zoning or land use law, regulation, policy or procedure that you believe is discriminatory
Coerced, intimidated, or threatened you to keep you from exercising your rights under the State or Federal
Fair Housing Law
Other (Explain)
When did the act(s) selected above occur?
Summarize in your own words what happened. Use this space for a brief and concise statement of facts.
Additional details may be submitted on an attachment. Sussex County Government will furnish a copy of the
complaint to the person or organization against whom the complaint is made.
I declare under penalty of perjury that I have read this complaint (including any attachments) and that it is
true and correct.
____________________________________________________
Signature
Date
THIS SHADED SECTION FOR COUNTY USE ONLY.
Intake Staff Name Filing Date File Number
Page 2 of 2
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Community Development & Housing (Sussex County Council)

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Completed 18 July 2020

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