Denied Housing Survey

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This form is used for collecting data from former justice involved/domestic violence individuals who lost housing assistance and denied after waiting the required 5 year waiting period.

The data will be used to create a report that will document how the current housing policies discriminate and target a particular population as well as adding to the increasing homeless problem in the Commonwealth of Massachusetts.

Email *

First Name *

Last Name *

Facility Name of halfway house

Street Address

City

State

Zip Code

Phone Number

Gender *

Race *

Age *

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