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

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.) *

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. *

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.

Would you like to sign up to receive information about workshops, webinars, or other training about Fair Housing?

Yes

No

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