CITY OF ST. PETERSBURG COMMUNITY AFFAIRS DEPARTMENT HUMAN RELATIONS DIVISION FAIR HOUSING COMPLAINT OF DISCRIMINATION INTAKE FORM

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1 CITY OF ST. PETERSBURG COMMUNITY AFFAIRS DEPARTMENT HUMAN RELATIONS DIVISION FAIR HOUSING COMPLAINT OF DISCRIMINATION INTAKE FORM IF YOU NEED ASSISTANCE COMPLETING OR HAVE QUESTIONS RELATED TO THE INTAKE FORM, YOU MAY CALL THE COMMUNITY AFFAIRS DEPARTMENT AT (727) or for TDD/TTY (727) COMPLAINANT INFORMATION: ( PLEASE LEGIBLY PRINT ANY INFORMATION PROVIDED ) Name: Address: SS# Driver s License # Pager #: ( ) - Cellular Phone #: ( ) - Address: COMPLAINANT S ALTERNATE CONTACT INFORMATION: Please provide information on a person (preferably someone who does not live with you) who will know how to get in touch with you at all times. Name: Relationship: Address: City: State: Zip Code: Pager # ( ) - Cellular Phone #: ( ) - Address: MINOR CHILDREN OF COMPLAINANT: Minor children of the Complainant (including children in the legal custody of the Complainant) who have been harmed by the alleged discriminatory acts: Name: Name: Name: Name: Date of Birth: Date of Birth: Date of Birth: Date of Birth:

2 OTHER AGGRIEVED PERSONS: Other individuals who have been harmed by the alleged discriminatory acts: Name: Address: SS# Driver s License # Pager #: ( ) - Cellular Phone #: ( ) - Relationship to Complainant: Name: Address: SS# Driver s License # Pager #: ( ) - Cellular Phone #: ( ) - Relationship to Complainant: BASIS OF THE COMPLAINT: A complaint may have multiple bases. Please check each basis that you believe was a reason that you were discriminated against by the Respondent(s). Race ( ) Color ( ) Sex* ( ) National Origin** ( ) Religion ( ) Familial Status*** ( ) Sexual Orientation ( ) Retaliation ( ) Disability**** ( ) *Sex includes Sexual Harassment. **National Origin includes ethnicity and physical, linguistic, or cultural traits. ***Familial status refers to one or more individuals (under the age of 18) who are domiciled with either a parent or another person having legal custody of such individual or a designee of the parent or legal guardian, an individual who is in the process of obtaining such custody, or an individual who is pregnant. ****Disability questionnaire must also be completed. HARM SUFFERED: Please describe the type of harm that you have allegedly suffered. (i.e., failure or refusal to rent or show property to you, eviction or threat of eviction, non-renewal of lease, failure or refusal to sell or show property to you, failure to provide service to you or unequal service provided, failure to reasonably accommodate your disability, denial of a loan for the purchase, refinance, or improvement of residential real property, etc. ) Harm: Date of Harm: 2

3 REAL PROPERTY INVOLVED: Please provide the following information regarding the residential real property involved: Street Address:_ City: State: County: Zip Code: Owner(s) of Property (if known): Address of owner(s) (if known): Type of property: Single family home: Duplex/2 family: 3 or 4 family: Multi-family structure: Condominium or Home Owners Association: Please answer yes, no, or don t know to each of the following questions with regard to the real property involved: 1. To your knowledge and/or belief is the real property owned or operated by a religious organization? If yes, what is the name of the religious organization? 2. To your knowledge and/or belief is the real property owned or operated by a private club (not open to the public) for the occupancy of club members only? If yes, what is the name of the private club? 3. To your knowledge and/or belief is the real property operated as Senior Housing? 4. If the real property has 4 or less units, to your knowledge and/or belief does the owner of the real property maintain and occupy one of those units as his/her residence? RESPONDENT(S): Provide the complete name (s ) of the person (s) or entities whom you believe to be responsible for the alleged discrimination. Name: Title: Company Name: Business Address: City: State: Zip Code: Telephone Number: ( ) - Name: Title: Company Name: Business Address: City: State: Zip Code: Telephone Number: ( ) - 3

4 Name: Title: Company Name: Business Address: City: State: Zip Code: Telephone Number: ( ) - ALLEGED DISCRIMINATORY ACTS OR CONDUCT: Describe in detail the acts or conduct that led you to want to file a Complaint of Discrimination. Please describe not only what happened, but explain why you believe that it was because of or related to your membership in a protected basis (i.e., race, color, religion, national origin, etc.) Provide the complete names of all individuals involved, if known, as well as the complete names of all witnesses to the acts or conduct, if known. (Use the reverse side of this page and additional paper, if necessary.) 4

5 CORROBORATION: Provide the complete information for any witnesses that you have that will provide written or oral testimony in support of your allegation of discrimination. Name: Address: Name: Address: 5

6 Name: Address: Name: Address: 6

7 Name: Address: ( Use additional paper, if necessary ) YOUR SUPPORTIVE DOCUMENTS: List the documents that you possess and will provide that support your allegation of discrimination. ( i.e. Lease, Application, Eviction Papers, Violation Notices, Advertisements, Sales Contracts, Loan Applications, etc.) OTHER SUPPORTIVE DOCUMENTS: List the documents that you believe to exist which support your allegation of discrimination, but to which you have no access. ( i.e. Leases, Applications, Eviction Papers, Violation Notices, Advertisements, Sales Contracts, Loan Applications, etc.)

8 COMPARATIVES: List all persons, by complete name, who are different from you ( i.e. Male/Female, Black/White/Hispanic/Asian, Disabled/Non-Disabled, etc.), but were treated more favorably than you under the same or similar circumstances. 1. Name: 2. Name: Difference: Difference: 3. Name: 4. Name: Difference: Difference: 5. Name: 6. Name: Difference: Difference: GENERAL FILING INFORMATION: Did you file a complaint regarding these same issues with any other entity? ( i.e., HUD, Pinellas County Office of Human Rights, Code Enforcement, Pinellas County Circuit or County Court, Federal Court, etc.) YES ( ) NO ( ) If yes, please identify the agency and person with whom the complaint was filed. Agency Name: Address: City: State: Zip Code: Person: Title: 8

9 Telephone Number: ( ) - Date of filing: What were the results or disposition of the filing? DAMAGES: Did you receive a written copy of the results or disposition of the filing? YES ( ) NO ( ) If yes, will you provide the Community Affairs Department with a copy of the written results or disposition? YES ( ) NO ( ) Please explain the specific damages that you have incurred as a result of the alleged discrimination, such as increased rent, lost or additional deposits, emotional distress, moving expenses, or any other out-of-pocket expenses. RELIEF: Please explain what type of relief you are seeking from the Respondent. AFFIRMATION & RELEASE I, the undersigned, affirm that, to the best of my knowledge, the information contained in this Fair Housing Complaint of Discrimination Intake Form is complete, true and factual. I also understand, agree and give permission to the St. Petersburg Community Affairs Department, Human Relations Division to request and receive any information necessary to resolve the material issues of a Complaint of Discrimination. This permission includes, but is not limited to, Financial and Medical Records. I also understand and agree that the primary obligation to secure and provide supportive documentation, including witness statements, for my Complaint of Discrimination is mine and not that of the St. Petersburg Community Affairs Department, Human Relations Division. In addition, I will provide such documentation and/or information in a timely manner. Signature Date Last Revised 9