Fair Housing Complaint Form

Name:
Street Address:
City:	Zip:
Home Phone:
Alternate Phone:
Discriminatory Act(s) Targeted One or More of the Following Personal Characteristics: Race Color National Origin Sex Familial Status (Children) Marital Status Source of Income Religion Sexual Orientation Age Disability Ancestry Other Briefly describe why you feel that you are a victim of housing discrimination (please limit your description to 150 characters or less)

Note: The alleged housing discrimination must have taken place in Orange County for our agency to investigate your complaint. A fair housing counselor will contact you shortly to discuss your allegations and obtain additional information.