Form Erd-10240 - Discrimination Complaint Fair Housing

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For Office Use
ERD Case #
State of Wisconsin
Discrimination Complaint
CR
Dept of Workforce Development
Fair Housing
Equal Rights Division
Important!! Please Read All Of The Instructions On Page 3 Before Starting
Type Or Print In Black Ink
Personal information you provide may be used for secondary purposes. [Privacy Law, s.
15.04 (1)(m) Wisconsin Statutes].
1. Complainant Information
2. Respondent Information
Last Name
Name of the housing provider you believe discriminated
against you. If more than one respondent, list each
separately on extra sheet.
First Name
Initial
Street Address
City
State
Zip Code
Street Address
Home Telephone Number
City
State
Zip Code
(
)
Work Telephone Number
Telephone number
(
)
(
)
3. Your complaint may be filed with another agency unless you check “no” below
Yes
See #3, in the instructions page, for more details
No
4. County in which the discrimination occurred?
Name of County
5. BASIS:
You must list a basis for your complaint. (For example: “sex-female,” “race-African American,”
“disability-visual impairment,” “sexual orientation-homosexual,” etc
What is the basis for your complaint
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ERD-10240 (R. 05/2010)

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