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Home > File a Charge > Housing 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.

Your Contact Information

Name: (First) * (Middle Initial) (Last) *

Mailing Address *

City *

State *

Zip *

County *

Home Phone

Cell Phone

Work Phone

Email Address

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

Mailing Address

City

State

Zip

Country

Type of Discrimination

I believe I have been discriminated against in housing based on (check all that apply): *

Race

Color

Sex

Sexual Orientation

Religion

National origin/Ancestry

Minor children. I am the

Receipt of public assistance (indicate type: )

Physical disability (indicate type: )

Mental disability (indicate type: )

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

The people/companies that discriminated is/are:

Person 1:

Name *

Home phone

Work phone *

Mailing Address *

City *

County

State *

Zip *

Person 2:

Name

Home phone

Work phone

Mailing Address

City

County

State

Zip

Person 3:

Name

Home phone

Work phone

mailing Address

City

County

State

Zip

Earliest date of discrimination *

Latest date of discrimination *

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

Do you have the money for rent and the security deposit? *

Provide a detailed account of your discrimination complaint in the space below:

(Rev. 8/05)

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