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











(example: 207-123-4567)

(example: 207-123-4567)

(example: 207-123-4567)

List all other members of your household:

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




(207-123-4567)


Type of Discrimination








( )
( )
( )

Property Details

The property involved is located at:



Type of housing involved: ( )


Discrimination Details

Person 1:


(207-123-4567)

(example: 207-123-4567)


Person 2


(207-123-4567)

(example: 207-123-4567)


Person 3:



(207-123-4567)

(example: 207-123-4567)





(example: 01/01/2014) (example: 01/01/2014)

 

Type of discrimination involved: (Check all that apply) *





(example: $567.89)
Provide a detailed account of your discrimination complaint in the space below:

(Rev. 04/14)