Indicates required field Your Information First name Last name M.I. Email address I do not have an email address Phone number I do not have a phone number Date of birth Address line 1 Address line 2 City State Zip Code Accused Parties Company Information Company name, if applicable Email address Phone number Address line 1 Address line 2 City State Zip Code Individual(s) Information Person 1 First name Last name Title Phone number Person 2 First name Last name Title Phone number Person 3 First name Last name Title Phone number Person 4 First name Last name Title Phone number Add another personRemove person Alleged Discrimination Category - Select -Employment (Non-County)HousingPublic AccommodationCounty Services (Title VI)Other Please specify other Basis Check only the boxes that you believe were the reasons for discrimination.This office may only accept complaints of discrimination based on one or more of the above reasons. If you do not see anything in this list that applies to your situation, please contact the Division of Human Rights by email or phone to speak to a staff member. Basis AgeCitizenship/Immigration StatusCreed/ReligionDisabilityFamilial StatusGender Identity/ExpressionGenetic InformationLawful OccupationMarital StatusMilitary StatusNational Origin/AncestryRace/ColorRetaliationSexSexual OrientationSource of IncomeVeteran Status Age Citizenship/Immigration Status Creed/Religion Disability Familial Status Gender Identity/Expression Genetic Information Lawful Occupation Marital Status Military Status National Origin/Ancestry Includes ancestry, culture, ethnicity, and language Race/Color Retaliation If you previously filed a discrimination case, were a witness to / helped someone else file a discrimination case, or opposed or reported discrimination of one of the categories listed on this form Sex Includes sexual stereotyping, sexual harassment, and pregnancy Sexual Orientation Source of Income Veteran Status Date of most recent incident Must be within one year of filing Incident location Description What did the person(s) or company you are complaining against do to discriminate against you? Please include dates, names of people involved, and explain why you think it was discriminatory based on the characteristics you identified above. Were there any witnesses to the alleged discrimination? Yes No Please provide witness name(s) and contact information What corrective action do you believe would address your complaint? Additional Information 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? File Upload? You may attach a document with information that you think is relevant to your complaint. Additional comments Accessibility Please outline any disability accommodations necessary for you to participate in the complaint proccess e.g. interpreter services, audio instructions, etc. Did you have any assistance filing this complaint? Yes No Please provide the name and contact information of the individual(s) who assisted you 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.
