Fillable NEW HAMPSHIRE COMMISSION FOR HUMAN RIGHTS 2 INDUSTRIAL (State of New Hampshire)

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NEW HAMPSHIRE COMMISSION FOR HUMAN RIGHTS 2 INDUSTRIAL (State of New Hampshire)

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CONFIDENTIAL
SENDING THIS QUESTIONNAIRE IS NOT SUBMITTING A CHARGE
Revised 6/2019
☐
NEW HAMPSHIRE COMMISSION FOR HUMAN RIGHTS
2 INDUSTRIAL PARK DRIVE
CONCORD, NEW HAMPSHIRE 03301
(603) 271-2767
FAX: (603) 271-6339
TTD ACCESS: RELAY NH 1-800-735-2964
Email: humanrights@nh.gov
HOUSING & COMMERCIAL PROPERTY INTAKE QUESTIONNAIRE
INSTRUCTIONS: This is a questionnaire meant to gather information, not a charge of discrimination. Please
fill out this questionnaire as completely as possible and send it back to the Commission either via regular mail,
fax or email using the contact information above. Keep a copy of the completed questionnaire for your records.
A Commission Investigator will use this information to review whether you have the basis to file a formal charge.
The Investigator will contact you after review to gather further information as necessary and either explain the
next steps in filing a formal charge or explain why you may not have the basis to file a charge of discrimination.
Your Name: Today’s Date:
Address:
City: State: Zip Code:
Telephone numbers: Home/Mobile: Work:
Email address:
Date of Birth (if age claim):
1. Who are you filing against?
Landlord Owner Bank Managing Agent Lessee
Sub lessee Assignee Builder Agent Salesperson
Other
2. Name:
Address:
City: State: Zip code:
Telephone: County:
3. Location of Property:
Address: Apartment No:
City: State: Zip code:
4. Property Type:
House Single Family Duplex Multifamily
Number of such homes owned by Respondent:
Is broker/agent/salesman being used?
Are ads expressing a preference/limitation or discrimination being used: Yes No
Apartment Number of Apartments
Does the owner or member of owner’s family reside in one of the dwelling units? Yes No
CONFIDENTIAL
SENDING THIS QUESTIONNAIRE IS NOT SUBMITTING A CHARGE
Revised 6/2019
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
Other
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.
CONFIDENTIAL
SENDING THIS QUESTIONNAIRE IS NOT SUBMITTING A CHARGE
Revised 6/2019
8. First date of Discrimination: Month Day Year
Last date of Discrimination: Month Day Year
*Please keep in mind that you only have 180 days from the last date of discrimination to file a Charge of Discrimination
with the Commission under state law
9. If not included in your response to Number 7 above, how did you become aware of the property?
Ad/Paper/Word of mouth: Date: Date called:
Who talked to: Date:
Reason given for rejection/decision:
10. Disability Discrimination Charges (additional information which may be relevant):
Does the complaint relate to accessibility in a residential property? Yes No
11. If yes, is/was the property:
(a) a building with one or more elevators? Yes No
(b) a ground floor unit in a building consisting of 4 or more units? Yes No
(c) designed and constructed for first occupancy after March 13, 19191? Yes No
12. Have you sought any assistance about the action you think was discriminatory from any other government
agency, union or from any other source?
Yes No If yes, indicate:
Name of source of assistance:
Result if any:
Keep a copy of the completed questionnaire for your records.
_________________________________________________________________________________________________
FOR AGENCY ACTION ONLY
Action taken:
[
]
Charge taken
[
]
Not a covered basis
[
[
[
]
]
]
Information only
Not a timely charge
CP is a federal employee
[
[
]
]
Actions complained of do not state
valid claim
No employer/employee relationship
[
[
]
]
CP chose not to file
Not enough employees
[
]
Referred to another agency:
[
]
Charge already filed at another
agency
[
]
Other reason (Specify):
[
]
Civil action already filed in court on
same basis
Investigator’s initials: Date:
Letter sent: Date: Initials:
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NEW HAMPSHIRE COMMISSION FOR HUMAN RIGHTS 2 INDUSTRIAL (State of New Hampshire)

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Completed 21 July 2020

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