Vermont Human Rights Commission, Questionnaire for Housing Complaints

Race Black White Asian Pacific Islander/Hawaiian
Native American Indian/Alaskan Native Other (please
specify)

Color

National Origin (please specify)

Religion (please specify)

Sex Male Female Nonbinary

Sexual Orientation (please specify)

Gender Identity (please specify)

Marital Status Married Single Divorced Widowed

Age

Disability Physical Developmental Psychiatric/Emotional

Receipt of public assistance (including housing assistance) (please
specify type of assistance)
Presence of minor children

Victim of Domestic Violence

B. Housing action upon which your complaint is based (choose all
that apply):

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 Refusal to rent or sell Discrimination in financing

Falsely told that housing was not available Blockbusting

Harassment Denied reasonable accommodation for disability

Denied reasonable modification for disability

Given different terms and conditions for rent/sale/loans

Discriminatory advertising Retaliation

Other (please specify)

C. What was the most recent date you were allegedly
discriminated against?

If your answer is more than one year before today, please stop and contact
the HRC at 800-416-2010 (Toll Free VT) or 802-828-1625.

3. RESPONDENT INFORMATION

Please provide the following information about the housing
provider/lending institution:

Landlord/Realtor/Lending institution:________________________________

Name of person you spoke/interacted with and title (if known): __________

_____________________________________________________________

Mailing address: _______________________________________________

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 _______________________________________________

Phone number: ________________________________________________
Email Address: ________________________________________________