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Fair Housing Discrimination Complaint Form

  1. If you have a complaint under Ordinance No. 95-92 or 2003-66 complete this form and mail or deliver it to the Carbondale City Clerk's Office, P.O. Box 2047, Carbondale, IL 62902-2047 within 30 days from the commission of the alleged violation or 180 days in the case of a relocation grievance.

  2. I may also be contacted through

  3. List the party or parties who allegedly discriminated against you

  4. Cause of discrimination (check all that apply)*

  5. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  6. AFFIDAVIT*

    I swear or affirm that I am the Complainant herein and that I have read the above complaint and that it is true to the best of my knowledge, information and belief.

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  8. This field is not part of the form submission.