Discrimination Complaint Service (DCS) Cuyahoga County Commissioners and the US Department of Housing & Urban Development funds HAI to investigate claims of illegal housing discrimination, represent claimants in litigation and/or administrative enforcement action, conduct tests to determine compliance with federal, state and local fair housing laws, and provide education to housing consumers, housing industry professionals, and Fair Housing Law Clinic Students. If you believe that you have been discriminated against in housing, lending or insurance products fill out this Housing Discrimination Intake Form and fax it to 216-431-6149, or call 216-431-7400. THE HOUSING ADVOCATES, INC. Initial Complaint Intake Form Referred to HAI by:___________________ Complaint Information: Name_________________________________________________ Phone day____________________ Evening_________________ Address_______________________________________________ City_________________________ Cell/Pager_______________ Single female head of household?______ Race?______ Ethnicity?__________Age?____________ Type of Case (Check all that may apply): Discrimination: Race___ Religion___ National Origin____ Familial Status____ Sex ____ Disability _____ Other____ (Describe:_________________________) Other: Predatory Lending___ Home repair___ Other Mortgage/Lending___ Harassment___ Landlord/tenant_____ Homeowners insurance___ Other ___ (Describe:__________________________) Type of Housing in Question: Rental___ (single family___ double-family___ 2-4 units___ 5+ units___ ) Owner-occupied___ (single-family___ double___ condominium___ mobile/manufactured__ ) Is this your primary residence?_______________ Date of discrimination/conduct:________________ Most recent date of discrimination/conduct___________________ Notes (use reverse/additional sheets if necessary): Action taken: Refer for testing___ Counseling___ Dismissal___ Referral____ Other_____ (______________________________) Fair housing referral to substantially equivalent: OCRC___ Shaker___ Parma___ Other:________ Non-fair housing, referral to:__________________________________________ Set for formal intake___ (Date and time scheduled:______________________________ With:_______________________) HAI Attorney Approval:______________________________ Date_________ Time: ___________ intake ___________ supervisor IMPORTANT: THE ANSWERING OF YOUR INQUIRY DOES NOT CREATE AN ATTORNEY-CLIENT RELATIONSHIP. The answering of this questionnaire DOES NOT mean that we agree to represent you or take any other action on your behalf. Unless we inform you in writing that we have agreed to investigate your complaint or represent you, you should consult with attorney for legal related advice
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