June 5, 2020 Tenant Advocacy Director Baltimore County Eviction Prevention and Housing Stabilization Intake Tenant Intake Baltimore County If you are human, leave this field blank. 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 * Email address 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 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
