SENDING THIS QUESTIONNAIRE IS NOT SUBMITTING A CHARGE
Condo Mobile Home Mobile Home Park Commercial
Rooming House Number of Rooms
Does the owner or member of the owner’s family reside in one of the rooms?
Is the unit for sale? Or for rent?
5. I believe I was discriminated against because of:
Age Creed Color Race
Sex Religion Marital Status Familial Status
Physical disability Mental disability Sexual Orientation
National Origin Gender Identity
If you checked race, indicate your race:
If you checked National Origin, indicate your National Origin:
The following question is voluntary if not checked above:
What is your Race? What is your National Origin?
6. Please check the alleged discriminatory action/condition:
Refusal to rent Refusal to sell Terms/conditions of rental
Refusal to mortgage Advertising Terms/conditions of sale
Refusal to provide disability accommodations Provision of services or facilities
Representation that dwelling or commercial structure is not available
Eviction solely on grounds that person has acquired immune deficiency syndrome (AIDS) or is regarded to
have acquired immune deficiency syndrome. Yes No
Inducement or attempted inducement of a person to sell or rent a dwelling by representations regarding the
entry or prospective entry into the neighborhood of a person or persons of a particular age, sex, race, color,
marital status, familial status, physical or mental disability, religion, sexual orientation, national origin gender
identity. Yes No
7. Explain what action was taken against you that you believe to be discriminatory. Were other persons treated
differently than you? What harm, if any, was caused to you as a result of that action? Please include all relevant
names and dates. If you have any documents concerning the situation, please attach copies to your statement.
Please use a separate piece of paper if you need more room.