Montgomery county, Md - Portal Header
  Text Version  
Montgomery County Maryland
Home |Help | Site Map   seal
space
citizen
Montgomery County, MD - Text Version is Currently Unavailable
   News
   County Executive
   County Council
   Judiciary
   Departments 
   I Want To ...
   Services & Info.
   Online Services
   County Cable 6
   Education 
   Volunteers
   Careers 
   Contact Us

county stat
  REAL ESTATE COMPLAINT QUESTIONNAIRE
  Instructions for Complainants                                     Return to –Compliance Section
 

(1) Try to answer every question in the sections which apply to your complaint and give complete and detailed responses.

(2) Think carefully before answering each question.

(3) When you're done, click the "Submit" Button at the bottom of the form.

(4) This is not a formal complaint form. The Human Rights Office will determine whether you have submitted enough information to file a formal complaint. The Human Rights Office will send you a completed formal complaint for signature and notarization if you have provided sufficient evidence.

Sections A, B, and D must be completed. Fill out the rest of the sections that apply to you.

(*) required fields

 

Section A
Complainant Information - Person(s) filing complaint
*First Name:
  
Middle Initial:
*Last Name:
  
*Birthdate:
  
Age:
*Home Address:
 
*City:
  
*State:
*Zip Code:
    
*Home Phone Number:
(123-345-6789)
    
E-Mail Address
  
Fax Number:
Cell Phone/Pager:
(123-345-6789)
  
Business Address:
City:
State:
Zip Code:
  
Business Phone Number:
(123-345-6789)
  

 

Complainant's Attorney Information
Attorney's Name:
Office Address:
City:
State:
Zip Code:
  
Office Telephone Number:
  
What other agencies/organizations have you contacted for assistance??
 
Were you given a Case Number?
Yes (if yes, what is the case No.)

 

  top of page

 
Section B
Respondent - Lender, financial institution, person, housing provider, apartment complex, owner, real estate agent/broker, property management co. which committed act of discrimination
*Name of Respondent:
  
  (indicate if incorporated, limited partnership, etc.)
*Respondent's Address:
  
*City:
  
*State:
*Zip Code:
    
Telephone Number:
(123-345-6789)
  
 
If the actual place where the discrimination occurred is a different site than the Respondent's address listed above, provide the address where it happened: (NOTE: It MUST be located in Montgomery County, MD)
Address:
City:
State:
Zip Code:
  
Telephone Number:
(123-345-6789)
  
   
Corporate Name of Respondent (if known):
  (indicate if incorporated, limited partnership, etc.)
Corporate Address:
City:
State:
Zip Code:
  
Corporate Telephone Number:
(123-345-6789)
  

top of page

Section C
Disability
Are you alleging discrimination based on disability?
 If No skip this section

Describe how the Respondent became aware of your disability.
 
When did the Respondent become aware of your disability?
 
With whom from the Respondent did you speak to about your disability?
Name:
  
Does the Respondent believe/perceive that you have a disability?

What accommodation, if any, did you request from the respondent?

How did the housing provider respond to your request for an accommodation of your disability? ( i.e. was your request denied, did the respondent tell you the accommodation was too costly, did the respondent off your an alternative (specify), did the respondent tell you it would take more time, did the respondent tell you any modifications would be at your expense, etc ).

  top of page

Section D
General Information : How did discrimination occur?
*When did the alleged discriminatory act occur?
 
What was the discriminatory basis for the Respondent's action(s)?
 
   

top of page

Section E
Evictions
If your complaint involves an eviction action, why and when are you being asked to vacate the property (i.e. lease violation; owner wants possession of property, expiration of lease, nonpayment, etc.)? Why do you believe the action is discriminatory?

top of page

Section F
Lending Practices
If your complaint involves discriminatory lending practices, please identify the location of the property you wished to purchase and the reason you believe the treatment you received is discriminatory.

top of page

Section G
Terms and Conditions of Occupancy
If your complaint involves differential terms and conditions of occupancy (i.e. maintenance, access to services or facilities, etc.), please provide the date your requested maintenance or service or access, the response to your request, and why you believe your treatment was discriminatory.

 top of page

Section H
Advertising
If your complaint involves discriminatory real estate advertising, explain how you were effected by the discrimination and describe the advertisement.

  top of page

Section I
Refusal to Rent or Sell
Please describe the discrimination you experienced while trying to rent or buy commercial/residential real estate (include the address of the property, persons to whom you spoke, application & contract dates, etc.)?
Did you talk/complain to any company official about your treatment?
When did you talk to a company official, who was it, and what was their response?
How were you notified that you were denied?

  top of page

Section J
Supporting Information
Describe any comments you believe were proof of discriminatory intent and identify who made the comments and when the comments were made. Be specific.
Are there any other persons who have information about events which led you to believe you were being discriminated against? If so, identify each person and specifically describe what each person will tell the Commission.
Name
Relationship to you
Address