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)
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)
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?
If yes, what was your request? ________________________________________
7. If you believe you have been discriminated against, have you reported the incident?
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)
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?
12. What was the basis of the hate crime?
Source of Income
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)