Please provide the name of an individual at a different address in your
local area who would know how to reach you:
What is the name of the residential dwelling (owner, builder, landlord,
property manager, condominium association, realtor, etc.), or financial
institution (bank or other lender, salesperson, mortgage company, insurance
company, etc.) that you believe discriminated against you?
What action was taken against you that you believe to be discriminatory? (Check those that apply)
Refused to rent, sell, or deal with you
Falsely denied housing was available
Discriminated in broker's services
Discriminated in the conditions or teams of sale, rental occupancy or services or facilities
Advertised in a discriminatory way
Discriminated in financing
Intimidated, interfered, or coerced you to keep you form exercising your fair housing rights
OTHER (Please explain)
* What was the most recent date your alleged harm took place? (mm/dd/yyyy):
* State briefly: Why do you believe this action was taken against you? It is a violation of the law to deny you your housing rights for any of the following bases: Race, Color, National Origin, Sex, Religion, Sexual Orientation, Gender Identity/Expression, Age, Disability, Marital Status, Familial Status (families with children under 18) or Retaliation (retaliation based on a protected activity).
Normally, your identity as a Complainant will be disclosed to the organization which allegedly discriminated against you. Consent
Have you sought assistance about the action you think was discriminatory
from any agency, an attorney, HUD or from any other source?
Name of Assistance Source:
Result if Any:
Have you filed a housing charge in the past with HUD or the Tampa
Office of Human Rights or another local agency comparable to the Human Rights
Approximate Date Filed:
Charge Number (if known):
PRIVACY ACT STATEMENT: This form is covered by the Privacy Act of 1974;
Public Law 93-579 Filling out and bring or sending us this questionnaire does not mean that
you have filed a charge. Once you have submitted the
completed form, you will be contacted by our office within 10 days. If you
are not contacted in 10 days please call (813) 274-5835. Please be
advised that there are time limits to file a charge, generally within 180 days
or in some jurisdictions one (1) year of the alleged harm.
Office Mailing Address: 306 E. Jackson Street, 3N , Tampa, Florida, 33602
If you need an accommodation under the Americans with Disabilities Act to
complete the questionnaire, please call (813) 274-5835
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