Indicates required field Your Information First name Last name Email address I do not have an email address Phone number I do not have a phone number Work phone number Address Address line 1 Address line 2 City State Zip Code Offending Party Information Please provide information about the person(s) who you believe discriminated against you. Respondent 1 First name Last name Company, if applicable Title Address Phone number Respondent 2 First name Last name Company, if applicable Title Address Phone number Respondent 3 First name Last name Company, if applicable Title Address Phone number Respondent 4 First name Last name Company, if applicable Title Address Phone number Remove respondentAdd another respondent Incident Information What is the basis of the alleged discrimination, harassment or retaliation? Select all that apply Age Color Creed Disability Familial Status Gender Identity / Expression Genetic Information Limited English Proficiency (LEP) Marital Status National Origin / Ancestry Race Occupation Religion Retaliation Sexual Orientation Sex Source of Income Veteran Status When did the alleged discrimination, harassment or retaliation occur? Where did the alleged discrimination, harassment or retaliation occur? Provide information about the incident(s) that led you to file this complaint. Name the people who were involved and what they did to discriminate against you. Please include the names of any witnesses. Feel free to attach this information as a separate document in the Additional Information section. Have you filed this complaint anywhere else? e.g. Maryland Commission on Civil Rights, HUD, etc. Yes No Where and when did you file this complaint? Additional Information File Upload? You may attach a document with information that you think is relevant to your complaint. Accessibility Please outline any disability accommodations necessary for you to participate in the complaint proccess e.g. interpreter services, audio instructions, etc. Affirmation By signing my name below, I affirm that I have read the above charge(s) and that it is true to the best of my knowledge, information and belief. Signature Print a copy of this form for your records.
