Housing Intake Form

Please note this is an accessible version of our interactive intake form, if you do not require advanced accessibility (screen readers, etc., please use the interactive intake form.

Housing Intake Form

Note that required fields are marked with an asterisk. The form cannot be submitted unless all required fields are filled in. You may also download a printable PDF file of this form for mail submission. This file requires the free Adobe Reader. This document is also available in Arabic, French, Creole, Spanish, and Somali PDF.

*Indicates Required Fields

Your Contact Information

Email*	First Name*	Middle Initial	Last Name*
Mailing Address*	City*	State*	Zip*
County	Home Phone (example: 207-123-4567)	Cell Phone (example: 207-123-4567)	Work Phone (example: 207-123-4567)

List all other members of your household:

1. Name: Minor child?

2. Name: Minor child?

3. Name: Minor child?

4. Name: Minor child?

5. Name: Minor child?

6. Name: Minor child?

Name of a relative, friend or neighbor who would know how to reach you

Name	Relationship	Telephone Number (207-123-4567)
Mailing Address	City	State	Zip	County

Type of Discrimination

Property Details

The property involved is located at:
Street Address	City	State	Zip	County
Rental amount:	Security deposit:	Utilities included?		Name of apartment complex:

Type of housing involved:	Apartment ( If so, how many units in building?: ) Single family dwelling Mobile home park Owner-occupied
Number of bedrooms:	Number of rooms other than bedrooms:
How did you find out that the Maine Human Rights Commission handles housing discrimination complaints?:

Discrimination Details

Earliest date of discrimination * (example: 01/01/2014)	Latest date of discrimination * (example: 01/01/2014)
Is discrimination ongoing? *

Type of discrimination involved: (Check all that apply) *	Notice to Vacate Eviction Refusal to rent Harassment Discriminatory advertisement or statements Discriminatory terms and condition of Application Discriminatory terms and condition of Occupancy
Do you wish to obtain or retain the unit? *	Your monthly income (example: $567.89)
Do you have the money for rent and the security deposit? *
Provide a detailed account of your discrimination complaint in the space below:

(Rev. 02/22)

Maine.gov

Maine Human Rights Commission

Housing Intake Form

Housing Intake Form

Your Contact Information

List all other members of your household:

Name of a relative, friend or neighbor who would know how to reach you

Type of Discrimination

Property Details

The property involved is located at:

Discrimination Details

Person 3:

Person 1:
Name	Home Phone (207-123-4567)	Work Phone (example: 207-123-4567)
Street Address	City	State	Zip	County
Owner Manager Neighbor Broker Other:
Person 2
Name	Home Phone (207-123-4567)	Work Phone (example: 207-123-4567)
Mailing Address	City	State	Zip	County
Owner Manager Neighbor Broker Other:
Person 3:
Name	Home phone (207-123-4567)	Work phone (example: 207-123-4567)
Mailing Address	City	State	Zip	County
Owner Manager Neighbor Broker Other: