Housing Advocates, Inc. - Discrimination Complaint Services

3214 Prospect Ave East, Cleveland OH 44115
Tel 216-431-7400 Fax 216-431-6149

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 you have been discriminated against in housing, lending or insurance products fill out the attached form and fax it to 216-391-5404 or call 216-391-5444 ext 100.

THE HOUSING ADVOCATES, INC.

Initial Complaint Intake Form- Updated Aug 2005

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