Fair Housing Survey
1. Please indicate the ZIP Code of your residence
2. Have you ever experienced discrimination in housing? (If you answer no to this question skip to question 9)
 Yes
 No
3. Who do you believe discriminated against you?
 a landlord/property manager
 a real estate agent
 a mortgage lender
 a city/county staff person
4. Where did the act of discrimination occur?
 an apartment complex
 a condo development
 a single-family neighborhood
 a public or subsidized housing project
 a trailer or mobile home park
 when applying for city/county programs
5. On what basis do you believe you were discriminated against? (check all that apply)
 Race
 Color
 Religion
 National Origin
 Ancestry
 Gender
 Marital Status
 Age
 Sexual Orientation
 Family Status (e.g. single-parent with children, family with children or expecting a child)
 Source of Income (e.g. welfare, unemployment insurance)
 Disability (either you or someone close to you)
 Other (please specify) ____________________________________________
6. Have you ever been denied reasonable accommodation (flexibility) in rules, policies or practices to accommodate your disability?
 Yes
 No
 If yes, what was your request? ________________________________________
7. If you believe you have been discriminated against, have you reported the incident?
 Yes
 No
8. Why haven't you reported the incident?
 don't know where to report
 afraid of retaliation
 don't believe it makes any difference
 too much trouble
9. If you own your home, are you in the foreclosure process or at risk of foreclosure? (If you answer no to this question skip to question 11)
 Yes
 No
10. Are you in foreclosure or at risk of foreclosure due to (check all that apply):
 I owe more on the home than it is worth so why should I keep paying the mortgage?
 Loss of income/unemployment
 Monthly payment is/will increase, and we are unable to refinance home to a lower interest rate
 Monthly payment is/will increase, and we are unable to refinance home to a fixed-rate loan
 A large one-time payment, built into the structure of the mortgage and due on a specific date, is required
 Significant increases in other housing costs (e.g. insurance, taxes, utilities, etc.)
11. Has any hate crime been committed in your neighborhood?
 Yes
 No
 Don't know
12. What was the basis of the hate crime?
 Race
 Color
 Religion
 National Origin
 Ancestry
 Gender
 Marital Status
 Sexual Orientation
 Age
 Family Status
 Source of Income
 Disability
If you feel that you have been a victim of discrimination you may call and report the violation to: 1 (800) 669-9777 (Toll Free) or 1 (800) 927-9275 (TTY)


Submit
~Glory to God in the highest, and on earth peace, good will toward men. Luke 2:14~