Housing Intake Form - Fair Housing Action Center of Maryland

I am a... *

Landlord

Tenant

Neither

Your Name *

Your email address *

Your phone number

Street Address of the property you're contacting us about *

City and State *

Zip Code *

County or City *

Name of Apartment Complex (if you live in an apartment) and Property Management Company or Landlord *

Race *

Your Gender *

Female

Male

Transgender

Other

Your age *

Your CURRENT total combined yearly household income, in whole dollars. Please include income for all family members/people living in your home. *

Your monthly rent or mortgage payment, in whole dollars

Number of adults living in the home *

Number of children living in the home *

Do you receive a housing subsidy? *

Yes

No

Please list the type of subsidy and the name of the agency that issued/manages your subsidy.

Do you have a disability? *

Yes

No

Please describe your landlord-tenant issue here. (Please be as detailed as possible.) *

Which organizations have you contacted about this issue before contacting us? *

How did you hear about the Fair Housing Action Center of Maryland? *

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/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.

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