Form Erd-10240 - Discrimination Complaint Fair Housing Page 4
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4Equal Rights Complaint Process Information
For effective complaint handling, please complete and return the following information with your
complaint.
Complainant First Name
Complainant Middle Name or Initial
Complainant Last Name
Current Date
Complainant Date of Birth (requested for identification purposes) mm/dd/yyyy
Availability:
(Important! You must notify the Department if you change your address or phone number. If
we are unable to locate you, your complaint may be dismissed.)
What Days and times are you usually available to discuss your complaint?
_______________________________________________________________________________________
_______________________________________________________________________________________
Is there a telephone where we can reach you during the day?
Yes
No
If so, please provide the area code and number: (
)
In case we cannot reach you, please provide the name, address and phone number of a person who does not
reside with you but will always know where you live and how to reach you.
Name
Street Address
City
State
Zip Code
Telephone Number
(
)
Settlement Information
At this time, what would you accept to settle your complaint?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Complaint Information
Have you filed this charge with any other agency?
If so, name of agency?
Date Filed
Yes
No
Statistical Information
Complainant Sex
Complainant Race (check appropriate box or boxes)
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Black or African American
Asian
White
Unknown
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