Human Rights Online Request Form

Human Rights Online Request Form

Human Rights Department
City of Greensboro
Human Rights Department
300 W. Washington St
P.O. Box 3136
Greensboro, NC 27402-3136

Phone: 336-373-2038 Fax: 336-373-2505

Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes Chapter 132, their e-mail address is considered public record.
Please select the type of assistance you require:*

Fair Housing Assistance Program (FHAP)Landlord Tenant Dispute Program Mediation (LTDP)
Your name*

First NameLast Name
How may we contact you?

PhoneE-mailBy phone or e-mail
Please provide a phone number
Phone Number*
Best time to call

MorningAfternoon
E-mail*
example@example.com
Are you a current resident?*

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
What housing issue(s) are you dealing with? Please check all that apply to your situation.*

Housing Discrimination based on Protected Class Status (Race, Color, National Origin, Religion, Sex [Including gender identity and sexual orientation], Familial Status, and Disability)Unresolved Maintenance Issues/Housing SafetyEviction/PadlockingCommunication Issues with Housing Provider/LandlordUnreturned Security DepositOther
Background Information
Age*
Household Income*
Race and Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic, Latino/a, or Spanish OriginMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhiteOther
Specify which Asian:*

Asian IndianChineseFilipinoJapaneseKoreaVietnameseOther
Specify which Hispanic, Latino/a, or Spanish Origin:*

CubanMexican, Mexican American, Chicano/aPuerto RicanSpanishOther
Landlord Information
Landlord's name*

First NameLast Name
Landlord's address*

Street Address

Street Address Line 2

CityState

Zip Code
Landlord's phone number*

Area CodePhone Number
Please provide a summary of what happened*

300 word limit0/300
What is your goal after submitting this form?*

300 word limit0/300
Do you need interpretation?*

YesNo
Please specify type of interpretation needed*
Should be Empty:

Human Rights Online Request Form

Background Information

Landlord Information