Vermont Human Rights Commission
Questionnaire for Housing Complaints
Your answers to this questionnaire are confidential pursuant to 9 V.S.A.
§4555(a). Please print or type your responses. If you have any
questions or require assistance while filling out this form, don’t
hesitate to contact the HRC at 1-800-416-2010 (Toll Free VT) or
802-828-1625 or by email at human.rights@vermont.gov.
1. INFORMATION ABOUT YOU
Name: ____________________________________________
Mailing address: ______________________________________________
______________________________________________
E-mail address: ______________________________________________
Home phone: ____________________Work phone: __________________
Cell phone: ___________________________________________________
Message phone 1: ________________ Message phone 2: ______________
If you will be represented by an attorney, please provide the attorney’s
name and phone number:
Name: __________________________ Phone number: _______________
Have you filed a complaint regarding this matter with the Human
Rights Commission, the U.S. Department of Housing and Urban
Development (HUD), or any other agency within the last year? Or
have you filed a lawsuit regarding this matter? If yes, fill in the
information below:
Agency or court name: _________________________________________
Approximate date complaint was filed: ______________________________
1
Complaint or charge number, if known: _____________________________
2. ESTABLISHING JURISDICTION
A. Below are the legal bases for protection from housing
discrimination. If you believe you have experienced
discrimination because of your membership in one or more of
these protected categories please choose all that apply.