The following is alleged to have occurred or is about to occur: *
Your answer
The alleged violation occurred because of: *
Your answer
Address and Location of the property in question *
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Respondents Addresses: *
Your answer
The following is a brief and concise statement of the facts regarding the alleged violation: *
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The most recent date on which the alleged discrimination occurred *
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The types of Federal Funds Identified *
Please sign and date this form. By signing this form you affirm the following: "I declare under penalty of perjury that I have read this complaint (including any attachments) and that it is true and correct. *