Fair Housing Center of Greater Boston

Intake Form

  1. Fill in the form below
  2. Print the form
  3. Send form to :
    The Fair Housing Center of Greater Boston
    59 Temple Place #1105
    Boston, MA 02111

Your Name
Your Address
City
State Zip Code
Daytime Phone
Evening Phone
If we cannot reach you, whom can we call?
Name
Phone Number

What happened to you?

How were you discriminated against? For example: were you refused an opportunity to rent or buy housing? Denied a loan? Treated differently from others seeking housing? Please state briefly what happened:

Why do you believe you are being discriminated against?

Race National Origin Disability
Color Family status/children Source of income (Section 8, public assistance)
Religion Sexual orientation

Please explain why you think your housing rights were denied:

Who do you believe discriminated against you?

Was it a landlord, owner, real estate agent, broker, bank, company, or organization? ______________________

Name
Address
City
Phone Number

Where did the alleged act of discrimination occur?

Address of Housing involved
Apartment #
Floor Number of bedrooms
Describe the neighborhood

How did you find out about the property?

Newspaper?
Paper Name
Date
Rental Agency?
Name
Address
Sign on Premises?
sign reads:
Word of Mouth?
Other?

When did this happen?

Date
Time of day

How did you find out about the Fair Housing Center?