Who else can we call if we cannot reach you?

Contact's name:	Daytime phone:
Best time to call:	Evening phone:
Contact's name:	Daytime phone:
Best time to call:	Evening phone:

What happened to you? How were you discriminated against? For example: Were you refused an opportunity to rent or buy housing? Denied a loan? Told that housing was not available when in fact it was? Treated differently from others seeking housing? State briefly what happened.

Why do you believe you are being discriminated against? It is a violation of the law to deny you your housing rights for any of the following reasons: race, color, religion, sex, national origin, familial status (families with children under 18), or disability. For example: were you denied housing because of your race? Were you denied a mortgage loan because of your religion? Turned down for an apartment because you have children? Were you harassed because you assisted someone in obtaining their fair housing rights? Briefly explain why you think your housing rights were denied because of any of the factors listed above.

Who do you believe discriminated against you? Was it a landlord, apartment manager, owner, bank, real estate agent, broker, company or organization?

Name:
Title/Position:
Address:
City:   State:   Zip code:

Where did the alleged act of discrimination occur? Provide the address and indicate the type of facility/dwelling. Was it at a rental unit? Single family home? Public or assisted housing? A mobile home? The rental office of an apartment complex? Did it occur at a bank or other lending institution?

Type:
Address:
City:   State:   Zip code:

When did the last act of discrimination occur?
Enter the date (mm/dd/yyyy)

Is the alleged discrimination on going? Yes No

Use the submit button below to e-mail your completed form to the intake officer: mary.b.enriquez@phoenix.gov

If you prefer, you may call, mail or fax the completed questionnaire to the Equal Opportunity Department at:

City of Phoenix Equal Opportunity Department
Compliance & Enforcement Division
251 W. Washington St. 7th Floor
Phoenix, AZ 85003
602-262-7486/voice     602-534-1557/TTY     602-495-0517/fax

Every attempt will be made to contact you within 48 hours of receipt of your complaint by the Equal Opportunity Department.

Before you submit this form, we would like you to be aware of the city's policy on the use of its e-mail systems. The policy states that the e-mail message you are about to send: (1) is subject to public disclosure under the Public Records Law, (2) is not private or confidential and (3) is retained for one month.