June 5, 2020 Tenant Advocacy Director Baltimore County Eviction Prevention and Housing Stabilization Intake Tenant Intake Baltimore County Is this a landlord-tenant or Fair Housing/Discrimination Complaint? * Landlord-Tenant Fair Housing/Discrimination Both Your Name Street Address of the property you're contacting us about * City and State * Zip Code * Your email address Name of Landlord or Property Management Company * Is English the primary language spoken in your household? * Yes No Would you consider your English proficiency to be (pick one of the following) * Good Fair No English Proficiency What is the primary language spoken in your home? Race (Due to Federal reporting regulations, please only choose one option) * American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Pacific Islander White Are You Hispanic or Latinx? * Yes No Your Gender (Due to Federal reporting regulations, please only choose one option) * Female Male Transgender Non-Binary Other Your age * Your total combined yearly household income, in whole dollars. Please include income for all family members/people living in your home. * Number of adults living in the home * Number of children living in the home * Do you receive a housing subsidy? (Tenants Only) * Yes No If you receive a housing subsidy, please list the type of subsidy and the name of the agency that issued/manages your subsidy. (Tenants only) Do you have a disability? * Yes No Please describe your landlord-tenant issue here. (Please be as detailed as possible.) * Please describe your Fair Housing/Discrimination issue here. Provide a detailed description of the discriminatory incident, and include links to advertisements for rental housing or properties for sale, and the names of any realtors or property managers involved. * How did you hear about the Fair Housing Action Center of Maryland? * If you are a tenant, are you aware that Maryland has a Renter's Tax Credit? * Yes No Would you like more information on the Maryland Renter's Tax Credit, or assistance with filling out the application? Yes No Would you like a referral for financial counseling or coaching? * Yes No The Fair Housing Action Center of Maryland works to advance an agenda of Fair Housing and housing equity in Maryland through legislative advocacy and research. Examples include signing a petition or contacting your elected officials. Would you be interested in hearing about opportunities to participate in the advocacy process? * Yes No Would you be interested in sharing your story with the media? * Yes, but only with all identifying information removed Yes, and you may use my name. Not interested at all. reCAPTCHA Submit If you are human, leave this field blank.
