Form Erd-10240 - Discrimination Complaint Fair Housing

EQUAL RIGHTS COMPLAINT PROCESS INFORMATION

è For effective complaint handling, please complete and return the following information with your complaint.

Today’ s Date

Your Full Name (last, first, middle initial)

Social Security Number

Not mandatory - used only for internal identification, accessibility

and accuracy of records within the Equal Rights Division.

WITNESSES: Please include the names, home addresses and telephone numbers of persons who know what happened

to you or may have seen, heard or experienced treatment similar to yours. Witnesses are not character references. They

are people who have relevant information about your complaint and are willing to cooperate in the investigation.

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AVAILABILITY: Please note below how you can be reached. (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.)

1. What days and times are you usually

available to discuss your complaint?

2. Is there a phone where we can reach you during the day?

If so, please provide the area code and number:

(

)

3. 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 .................................................................Address.........................................................................................

City, State, Zip Code......................................................................... Telephone (

)

SETTLEMENT INFORMATION:

At this time, what would you accept to settle your complaint? (Note: If discrimination is proven under state law you

may recover costs you incurred because of the discrimination, attorney fees, the housing you sought and other economic

and noneconomic damages you may have suffered. In a civil action, punitive damages may also be sought.)

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COMPLAINT INFORMATION:

Have you filed this charge with any other agency?

Yes

If so, name of agency:......................................................................................... Date filed: .........................................

Date of Birth:

STATISTICAL INFORMATION:

You Are:

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Male

Female

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African-American (Black)

White Nonhispanic

Asian/Pacific Islander

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Native-American/Alaskan Native