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
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
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.
THIS SHADED SECTION FOR COUNTY USE ONLY.
Intake Staff Name Filing Date File Number
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