[City of Charlotte] Housing Discrimination Complaint Form

The Complainant below charges the Respondent named below with a violation of the Charlotte Fair Housing Ordinance (Chapter 12, Article V of the Code of the City of Charlotte), or the Mecklenburg County Fair Housing Ordinance. Please only enter the minimal information concerning your complaint.

1. YOUR PERSONAL INFORMATION

Name

First Name

Last Name

Address

Street Address

City

State

Zip

Phone Number (Include area code)

Who else can we contact if we cannot reach you (include name, phone number, and full address)?

2. ENTER COMPLAINT INFORMATION

NOTE: It is a violation of the law to deny you housing rights for any of the following factors: race, color, religion, sex, national origin, disability or familial status (being pregnant or having children under the age of 18 years old).

How were you discriminated against? For example, were you refused an opportunity to rent or buy housing, denied a loan, falsely told housing wasn't available or treated differently from others seeking housing? Briefly describe what happened.

Why do you believe you were discriminated against? Which factor do you believe contributed to you being denied housing, financing, or being harassed?

Race

Color

Religion

Sex

National Origin

Family Status

Disability

Who do you believe discriminated against you? Please provide their name.

First Name

Last Name

What is their address (include city, state, zip code)?

Street Address

City

State

Zip

What is their phone number (include area code)?

If this person represents a company or organization, please provide the name and address (include the city, state, and zip).

What position does this person hold?

Real Estate Agent

Landlord

Broker

Other

If other, please list.

Where did the alleged act of discrimination occur?

Rental Unit

Single-Family Home

Broker's Office

Other

Provide the address where the alleged discrimination occurred (including city, state, zip).

Street Address

City

State

Zip

On what date did the last act of discrimination occur?

Is the alleged discrimination continuous and/or ongoing?

Yes

If Yes, please provide additional details

Have you filed a complaint with any other business, organization, court, or governmental organization?

Yes

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I swear or affirm that I have read this complaint (including any attachments) and that it is true to the best of my knowledge information or belief.

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First Name

Last Name

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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.

NOTE: Additional details will be collected by the investigator assigned to your case. The CRC will provide a copy of this complaint to the individual(s) or organization(s) against whom your complaint was made.

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Subscribed and sworn to before me this date:

Notary Public:

Date of Expiration of Commission:

This complaint is received for investigation on this date:

Charlotte-Mecklenburg Community Relations Committee, Director: