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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
13. Email Address*
15. Please briefly state what happened to you:*

    For example, how were you discriminated against? Were you refused an opportunity to rent or buy housing? Or denied a housing loan? Were you told that housing was not available when it actually was? Were you treated differently from other individuals seeking housing?

17. Why do you think you are a victim of housing discrimination?*

    Is it because of your:

    1. Race
    2. Color
    3. Religion
    4. Gender
    5. Sexual Orientation
    6. National Origin
    7. Disability
    8. Familial Status
    9. Other
19. Briefly explain why you think your housing rights were denied:*

    For example, were you denied housing because of your race or sexual orientation? Were you denied a mortgage loan because of your religion? Or turned down for an apartment because you have children?

21. Who do you believe discriminated against you?*

    For example, was it a landlord, owner, bank, real estate agent, broker, company, or organization?

23. Please identify who you believe discriminated against you:
25. First Name*
26. Last Name*
28. Phone Number*
29. Email Address*
31. Where did the alleged act of discrimination occur?*

    For example, was it at a rental unit? Single family home? Public or Assisted Housing? A mobile home? Did it occur at a bank or other lending institution?

    Please provide the address below:

33. Address*
34. City*
36. State*
37. Zip Code*
39. When did the last act of discrimination occur?*
    When did the last act of discrimination occur?

    When did the last act of discrimination occur?
41. Is the alleged discrimination continuing or ongoing? *
    -- Select One --YesNo
43. This form will be submitted to the Town of Pittsboro Planning Department. You will receive a response from a staff member as soon as possible. Thank you.
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47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

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