housing_intake

DISTRICT OF COLUMBIA GOVERNMENT

OFFICE OF HUMAN RIGHTS

HOUSING/COMMERCIAL SPACE INTAKE QUESTIONNAIRE

COMPLETING THIS INTAKE QUESTIONNAIRE DOES NOT CONSTITUTE THE FILING OF A DISCRIMINATION CHARGE.

Asterisks ( * ) are required fields.

1. COMPLAINANT

*Date:

*Name:

*Street Address:

*City:

*State:

*Zip:

(Format: NNN−NNN−NNNN)

Telephone (H):

Telephone (W):

Email:

*What language do you prefer to communicate in? :

English

Amharic

Chinese

Vietnamese

Korean

Spanish

Other

(Please list)

Do you require a reasonable accommodation? If so, Please explain

Do you require language interpretation? If so, what language

IF REPRESENTED BY COUNSEL, PLEASE PROVIDE THE FOLLOWING:

(Format: NNN−NNN−NNNN)

Name:

Telephone/Fax:

Street Address:

City

State

Zip

Please note: If you are represented by counsel or retain counsel prior to your scheduled Intake interview, the counsel must either (1) be present with you for the duration of your Intake interview, or (2) withdraw his/her appearance from the interview by submitting a letter to the Office indicating that the interview may take place without his/her representation.

2. RESPONDENT

The person that discriminated against you was:

Owner

Property manager

Leasing Agent

Maintenance person

Other

Place where discrimination occurred:

Single Family Home/Duplex

Apartment Complex

Condominium

Cooperative

Property Address

Date of Occurence

NAME OF ESTABLISHMENT (INCLUDE MANAGEMENT COMPANY:

NAME AND TITLE OF AGENT, REALTOR, BROKER:

Property Address

City

State

Zip

Tel/Fax #

e−mail Address

3. ISSUE OF COMPLAINT

*What action was taken that made you feel you were treated differently?

Refusal to rent/sell

Discriminatory Financing Terms

Failure to make an accommodation i.e. Disability

Discriminatory advertising, statements and notices

Retaliation, Harassment, Intimidation, Coercion

(i.e. Disability)

False Representation of Availability

Discriminatory terms, conditions, services and facilities

Other

4. BASIS OF COMPLAINT

The basis is one of the below listed categories to which you belong and believe

that you were treated differently because you belong or are perceived to belong in that category.

*Do you feel you were discriminated against because of your: (Please check appropriate box and provide detail, if necessary.)

Race

Sex

Source of Income

Political Affiliation

Place of Residence or Business

Matriculation

Color

Disability

Marital Status

National Origin

Gender Identity or expression

Status of a victim of an intra−family offense

Religion

Familial Status

Age

Sexual Orientation

Personal Appearance

5. JURISDICTION

Please check all that apply:

*Alleged violation occurred in the District of Columbia.

*Alleged violation occurred 365 days or less from today's date.

* You have not commenced any other action, civil, criminal, or administrative in any other forum based on the same unlawful discriminatory practice described herein.

6. WITNESS

List whom you feel can corroborate your experience and provide evidence in your support.

Name

e−mail Address

Phone Number

Name

e−mail Address

Phone Number

Name

e−mail Address

Phone Number

7. YOUR COMPLAINT

*Describe in detail the incident(s) that led you to file a complaint of discrimination. Please list dates as well as the name(s) of the person(s) who discriminated against you in denying goods, services, etc. If this is a disability−based complaint, please specify whether an accommodation was requested; the person the request was submitted to and the date Respondent was notified of your disability.

SUBMITTING THIS INTAKE QUESTIONNAIRE DOES NOT CONSTITUTE THE FILING OF A CHARGE. The DC Office of Human Rights was established to eradicate discrimination, increase equal opportunity and protect human rights for persons who live, work, or visit the District of Columbia. The receipt of this complaint form by the Office of Human Rights will lead to an intake interview.

*Signature

*Date