Housing or Employment Discrimination Claim Information Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

In Dayton Ohio and under federal statues, it is unlawful to discriminate against citizens/residents in housing and employment. If you believe you were denied housing, treated differently by your property owner, or a subject of discriminatory employment practices, please let us help you work through the administrative complaint process.

Complainant First Name *

Complainant Last Name *

Complainant Email Address *

Complainant Phone Number *

Preferred Method of Communication *

Phone

Other:

Respondents Name *

Respondents Address *

Respondents Phone Number *

Who is the Respondent? *

Person

Organization

Explain what happened? *

What date did the discriminatory event occur? *

YYYY

Do you have supporting evidence for your claim? *

Yes

Maybe

What area where you discriminated in? *

Housing

Employment

Other:

Are you a member of the protected classes listed below? *

Race

Color

Religion

Sex/Gender

Sexual Orientation

Gender Identity

National Origin

Ancestry

Martial Status

Familial Status

Disability/Handicap

Place of Birth

Other:

Required

Have you reported the Respondent's conduct to any of the listed agencies? *

Dayton NAACP

Miami Valley Fair Housing Center

Dayton Human Relations Councils

Have not reported to any agency

Ohio Civil Rights Commission

Equal Employment Opportunity Commission

Other:

Required

Do you have a attorney? *

Yes

Do you certified that all information listed in this form is true? *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Dayton Black Pride.

Does this form look suspicious? Report

Forms