Form Erd-10240 - Discrimination Complaint Fair Housing

IMPORTANT!!

PLEASE READ ALL INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)].

State of Wisconsin

ERD Case #

Discrimination Complaint

Department of Workforce Development

Equal Rights Division

Fair Housing

TYPE OR PRINT IN BLACK INK

1. Your name, street address, city, state, ZIP code:

2. Respondent Name (Name of housing provider or

person you believe discriminated against you. Include

street address, state and ZIP code.). If there is more

than one respondent, list each separately.

Your Phone Number (include area codes):

Home (

)

Work

(

)

4. Respondent Phone Number

3. Your complaint may be filed with another

(include area code):

(

)

agency unless you write “ no” here. See

#3 on reverse side for more details.

__________

5. County in which the

discrimination occurred:

6. BASIS: You must list a basis for your complaint. (For example: “ sex-female,” “ race-African American,” “ lawful

source of income-AFDC,” “ disability-visual impairment,” etc.)

What is the basis for your complaint? ........................................................................................................................

7. STATEMENT: What did the respondent do?

List each action that you believe was discriminatory. (For example: They refused to rent to me, I was evicted, they

charged higher rent, etc.) Then, say why you believe you were treated differently because of the basis you listed above.

...............................................................................................................................................................................................

8. DATES:

When did the above action(s) first happen? (mo/day/yr) .................................................................................................

On what date did it last happen? (mo/day/yr) .................................................................................................................

For Office Use

By my signature below, I acknowledge that I have read the complaint; that to the

best of my knowledge, information and belief the complaint is true and correct;

and that the complaint is not being used for any improper purpose such as to

harass the party against whom the complaint is filed.

..................................................................................................................

Signature of Complainant or Authorized Representative

ERD-10240 (R. 12/96)