_____________________________________________ __________
Signature Date
Mail or fax to:
Vermont Human Rights Commission
14-16 Baldwin Street
Montpelier, VT 05633-6301
Telephone: 800-416-2010 (Toll Free VT) or 802-828-1625
TTY: 877-294-9200
Fax:802-828-2481
Email: human.rights@vermont.gov
ADDITIONAL QUESTIONS FOR HOUSING DISCRIMINATION
CLAIMS
Please answer any or all of the following applicable questions either
directly on this form or on another sheet of paper. Additionally, you
are invited to provide any further information or documents you
believe would be helpful.
5
How and when did you find out about the housing unit for rent or for sale?
When did you first contact the landlord/owner/realtor?
Please describe your conversations/interactions with the
landlord/owner/realtor.
Did you submit a rental application or contract for sale? If yes, when?
How were you notified that the application or contract was being denied?
Are you a current resident at the property in question?
Do you live with children under the age of 18? If yes, please provide the
names and dates of birth of the child/ren.
6
Who discriminated against you?
What is their position?
Provide the names, contact information, and protected class of any persons
who were with you.
Was this a one-time incident or was the discriminatory conduct repeated?
Were there any witnesses to the incident(s) you described? If yes, please
provide names and contact information.
Did you report the incident(s) to anyone? If yes, when and to whom and
what did you tell that person?
7
Explain how the offensive conduct affected you. Did you suffer physically or
psychologically? Did you see a doctor or counselor/therapist?
Is there any documentation of the incident(s)?