Has a housing provider told you the apartment, house, or condominium is not available, when in fact it has not been rented or sold?

Yes

No

Has a housing provider refused to rent or sell to you because you are a member of one of the protected groups?

Yes

No

Has your home been appraised at a lower value because you are a member of a protected group?

Yes

No

Have you been given different terms or rules than others because you are a member of one of the protected group?

Yes

No

Have you seen written statements in a newspaper or been told by the property owner or its representative a statement that indicates preferences or limitations for certain people. This includes any ad or brochure that is created by the owner of the property.

Yes

No

Has someone attempted to prevent you from renting or buying a house in a neighborhood by suggesting that you will not be safe or that neighbors may not want you to move in.

Yes

No

Have you been told by a housing provider they don’t rent to families with children?

Yes

No

Has a housing provider propositioned you for sex in exchange for making repairs or getting a break in the rent?

Yes

N0

Have you experienced unwelcome sexual advances, physical or verbal contact?

Yes

No

Have you been told by a housing provider that you are not allowed to have visitors who are members of a protected class?

Yes

No

Name *

First Name

Last Name