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NFHA Preliminary Intake Form

Submit this form to NFHA if there is no state/local fair housing agency in your area.
We will review your submission and follow up to conduct an intake to see how we may be able to assist you or refer you to appropriate resources.

1. First Name *This question is required.

2. Last Name *This question is required.

3. Preferred Pronouns (optional)

4. Please Identify Your Race (Select all that apply) *This question is required.

Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Black or African American
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

5. Email Address *This question is required. This question requires a valid email address.

6. Phone Number *This question is required.

7. City *This question is required.

8. State *This question is required.

9. ZIP Code *This question is required.

10. Briefly describe the housing discrimination you experienced. *This question is required.

11. On which of the following do you believe the discrimination was based? *This question is required.

12. Who discriminated against you? *This question is required.

If not applicable, indicate "N/A"; if unknown, indicate "unknown."

Company/Organization name(s):
Individual name(s):

13. Most recent act of discrimination (Month/Year) *This question is required.

14. Have you contacted other organizations, including attorneys, about this matter? *This question is required.

15. Please name the organizations, or attorneys, that you've contacted about this matter: *This question is required.

15. Has a fair housing administrative complaint or lawsuit ever been filed in this matter? *This question is required.

16. Tell us about your administrative complaint or lawsuit: *This question is required.

	Venue (i.e. federal court, state court, HUD, or name of state/local government agency)
	Month/Year filed
	Status (i.e. pending, settled, dismissed, withdrawn, etc.)