Fair Housing Intake Form
Are you a landlord? ¿Eres arrendador?
Please select...
NO, I AM NOT A LANDLORD (no soy arrendador)
Yes / Sí
Please note that we do not provide individual counseling services to landlords. For general information about fair housing and/or our education services, please visit our website at www.fairhousingnorcal.org.
Preferred Language/
Idioma Preferido
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English
Spanish
First Name
Last Name
Phone Number
Email
Street Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
5-Digit Zip / Postal Code
County
Please select...
Marin County
Sonoma County
Solano County
Contra Costa County
Napa County
Alameda County
Mendocino County
Yolo County
Other
Are you a renter or homeowner?
Please select...
Renter
Homeowner
Lives with family
Homeless
How many years have you lived at your current address?
How many people are in your household?
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How many minor children are in your household?
Please select...
0
1
2
3
4
5
6
7
8
9
10
What is your annual household income?
What is your main source of income?
Please select...
Employment
Disability Benefits
Social Security
Retirement/ Pension
Alimony/ Child Support
Unemployment Benefits
Welfare/ General Assistance
Veteran Compensation
Other
Do you have a rental subsidy or voucher?
Please select...
Section 8 / Housing Choice Voucher
VASH (Veterans Voucher)
HOPWA
Project Based Section 8
Shelter Plus Care
Low Income Tax Credits
Other
No subsidy
Does anyone in your household have a mental or physical disability?
Please select...
No
Yes
Unknown
Is anyone in your household 62 or older?
Please select...
Yes
No
What is your gender?
Please select...
Female
Male
Transgender Female
Transgender Male
Nonbinary
Other gender
Prefer not to state
What is your race?
Please select...
White
Black / African American
Asian
Pacific Islander / Hawaiian
American Indian / Alaska Native
Black and white
Asian and white
Other multi-racial
What is your ethnicity?
Please select...
Hispanic / Latinx
Not Hispanic / Latinx
What is your date of birth? (MM/DD/YYYY)
Who are you having an issue with?
Please select...
Property manager
Leasing agent
Property owner/ landlord
Neighbor/ other tenant
Housing authority
Homeowner's association
Lender/ bank
Broker/ real estate agent
Appraiser
Tenant
Social Services
Mobile Home Owner
Other
Brief Description of Issue:
How were you impacted by Covid-19?
Please select...
Housing impacted
Finances impacted
Physical health impacted
Mental health impacted
My household was not impacted
How did you hear about Fair Housing Advocates?
Please select...
Internet search
Friend/ Family
Radio/ tv/ media
Legal Aid of Marin
LSNC
Legal Aid of Sonoma County
CRLA
Other legal aid/ legal services
Other fair housing organization
Housing Authority of Marin (MHA)
Housing Authority of Sonoma County
Housing Authority of Santa Rosa
Other Housing Authority
Catholic Charities
Adopt-a-Family
Center for Domestic Peace
Canal Alliance
DSLC
MCIL
Veterans Association
Other case manager/ advocate
Other
Nombre
Apellido
Numero de Teléfono
Correo electrónico
Dirección
Cuidad
Estado
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
C
ó
digo Postal
Condado
Please select...
Marin
Sonoma
Solano
Contra Costa
Napa
Alameda
Mendocino
Yolo
Otro
¿Eres inquilino o propietario?
Please select...
Inquilino
Propietario
No tengo casa
Dueno de casa
Otra
¿Cuántos años ha vivido en su casa/apartamento?
¿Número de personas en su familia?
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
¿Cuántos niños en su familia?
Please select...
0
1
2
3
4
5
6
7
8
9
10
¿Cuál es el ingreso anual de su familia?
¿De dónde provienen su ingreso?
Please select...
Su trabajo
Beneficios por discapacidad
Seguridad Social (SSI/ SSA)
Beneficios de jubilación
Manutención de los hijos
Beneficios de desempleado
Compensación de veteranos
Bienestar/Asistencia General
Otro
¿Alguien en su familia tiene una discapacidad?
Please select...
Sí
No
Prefiero no declarar
¿Tiene ayuda para pagar su alquiler?
Please select...
Section 8 / Housing Choice Voucher
VASH
HOPWA
Project Based Section 8
Low Income Tax Credits
Otro
No ayuda
¿Hay alguien en su familia mayor de 62 años?
Please select...
Sí
No
¿Cuál es su género?
Please select...
Mujer
Masculino
Mujer Transgénero
Transgénero Masculino
No-binario
Otro Género
Prefiero no declarar
Etnicidad
Please select...
Hispano / Latino
No Hispano / No Latino
Raza
Please select...
Blanco (incluyendo blanco Hispano)
Negro (incluyendo Negro Hispano)
Asiático (incluyendo Asiático Hispano)
Isleño del Pacífico / Hawaiano (incluyendo Hispano)
Indio Americano (incluyendo blanco Hispano)
Negro y blanco (incluyendo blanco Hispano)
Asiático y blanco (incluyendo blanco Hispano)
Otro Multirracial
Fecha de Nacimiento (MM/DD/YYYY)
Breve comentario sobre el asunto:
¿Cómo te afectó el Covid-19?
Please select...
Mi vivienda
Mis finanzas
Mi salud física
Mi salud mental
Mi familia no fue afectada
¿Quién te habló de nosotros?
Please select...
Internet
Amigo/ Familia
Radio/ TV
Legal Aid of Marin (LAM)
LSNC
Legal Aid of Sonoma County
CRLA
Otra asistencia legal
Otra organización de fair housing
Housing Authority of Marin (MHA)
Housing Authority of Sonoma County
Housing Authority of Santa Rosa
Otra autoridad de vivienda
Catholic Charities
Adopt-a-Family
Center for Domestic Peace
Canal Alliance
DSLC
MCIL
Veterans Association
Otro defensor o asistencia
Otro
Contact Information