[DC GOVERNMENT] Housing or Commercial Space Questionnaire Form

Housing or Commercial Space Questionnaire Form

Submitting this complaint questionnaire does not constitute the formal filing of a discrimination charge, but it serves to preserve all rights under the statute of limitations. The formal filing will take place when we review your questionnaire and hold an intake interview with you at the OHR Office.

How do you prefer we contact you?

Phone

Mail(using address provided)

What language do you prefer to communicate in?

Do you require a reasonable accommodation? If so, please explain.

Do you require language interpretation? If so, what language?

Are you represented by counsel?

YES

Please note: If you are represented by counsel or retain counsel prior to your scheduled Intake interview, the counsel must either (1) be present with you for the duration of your Intake interview, or (2) withdraw his/her appearance from the interview by submitting a letter to the Office indicating that the interview may take place without his/her representation

Respondent Full Name

Respondent Phone Number

Respondent Fax Number

Respondent Title

Owner

Property Mananger

Leasing Agent

Maintenance Person

Other

If Other, Please Specify

Place where discrimination occurred:

Single Family Home/Duplex

Apartment Complex

Financial Institution

Condominium

Cooperative

Do you feel you were discriminated against because of your: (Please check appropriate box and provide detail, if necessary.)

If Other, Please Specify

What action was taken that made you feel you were treated differently?

If Other, please Specify

Must be checked

You have not commenced any other action, civil, criminal or administrative in any other forum based on the same unlawful discriminatory practice described herein.

Must be checked

Alleged violation occurred 365 days or less from today’s date.

.Must be checked

Alleged violation occurred in the District of Columbia.

Please provide a statement of the key events, including relevant dates and how the bases and issues you indicated above are connected. If this information is not included your complaint may be dismissed

How did you hear about the DC Office of Human Rights (check all that apply)?

Additional Referral Information

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Agreement

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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1. Complainant Information

Housing or Commercial Space Questionnaire Form

Full Address

How do you prefer we contact you?

Are you represented by counsel?

Full Address

Respondent Company Address

Respondent Title

Place where discrimination occurred:

Property Address

Date of Occurrence *

Do you feel you were discriminated against because of your: (Please check appropriate box and provide detail, if necessary.)

What action was taken that made you feel you were treated differently?

Must be checked

Must be checked

.Must be checked

How did you hear about the DC Office of Human Rights (check all that apply)?

Full Name

Sign Here

Agreement

Date Picker

Full Name