Housing Intake Form | Fair Housing Action Center of Maryland

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 (If you don't have access to email, please provide a phone number.)

Race *

Your Gender *

Female

Male

Transgender

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

If this is a Landlord-Tenant Issue, please enter the information here. (Please be as detailed as possible.)

If this is a Fair Housing/Discrimination Issue, please provide a detailed description of the discriminatory incident below, including 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

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