Address of the property in question: _____________________________
_____________________________________________________________
Type of house or property involved (please choose one):
• Single family home
• Rental unit in multiple unit building (more than 3 units)
• Rental unit in multiple unit building (3 or less units)
o For rental units located in a building of 3 units or less, is one of
the units occupied by the owner or a member of the owner’s
immediate family? YES NO UNKNOWN
Please provide information about what happened. Include dates the
alleged discrimination occurred, names and titles (if applicable) of
who discriminated against you, the name of who you reported it to,
and action taken (if any). If the discriminatory action is based on a
disability please include information including the nature of your
disability, the date of your medical diagnosis and nature of your
request (e.g. assistance animal, structural modification, etc.):
4
I understand that the information in this questionnaire may be
shared, in whole or part, by the Vermont Human Rights Commission
(HRC) with the U.S. Department of Housing and Urban Development
and the Respondent identified above.
In order to provide a timely complaint, under penalties of perjury, I
declare that I have read this questionnaire and wish to make it my
complaint of discrimination and that the facts stated in it are true. I
will advise the HRC if I change my address or telephone number and
I will cooperate fully with the HRC in the processing of my complaint
in accordance with its procedures.
I understand the foregoing and agree to and request the HRC
consider an investigation of this matter. I understand that the
information provided does not guarantee acceptance of a complaint.