COMMONWEALTH OF PENNSYLVANIA
GOVERNOR’S OFFICE
PENNSYLVANIA HUMAN RELATIONS COMMISSION
______________________________ , :
Complainant(s) : PHRC Case No.
:
v. : HUD No.
:
______________________________ , :
Respondent(s) :
COMPLAINT
1. COMPLAINANT(S)
2. RESPONDENT(S)
(person, landlord,owner, housing provider, or other entity against whom you are filing this complaint)
3. Address of property at issue (hereinafter "the subject property":
4a. I began renting the subject property from Respondent on ______________________.
4b. I applied to rent the subject property from Respondent on ______________________.
5. Protected Class(es) (check all reasons you have been discriminated against and specify the
class, e.g. race, African American; sex, female)
Race: Religious Creed:
Color: National Origin:
Sex: Ancestry:
Age/Date of Birth: Retaliation
Disability: Use of Guide or Support Animal
Familial Status: Other (specify):
PHRC Housing Complaint, Rev. 9-2020
Page 1 of 3
6. Dates of Discrimination:
Beginning: _______________ Ending: _______________
Continuing? Yes No
7. DESCRIBE THE DISCRIMINATORY CONDUCT, WITH SPECIFICITY, AND
EXPLAIN HOW THE DISCRIMINATORY CONDUCT IS RELATED TO YOUR
PROTECTED CLASS:
(e.g. failure to rent, termination of lease, denial of disability accommodation, retaliation,
different terms and conditions of housing)
WARNING: FAILURE TO COMPLETE THIS SECTION MAY RESULT IN YOUR
COMPLAINT BEING REJECTED FOR INSUFFICIENCY.
PHRC Housing Complaint, Rev. 9-2020
Page 2 of 3
8. Based upon the foregoing, I/we allege that the Respondent(s) violated Section 5 of the
Pennsylvania Human Relations Act, 43 P.S. §§ 951-963.