Division of Human and Civil Rights

Equal Accommodations (EA) Intake Questionnaire

* The Statute of limitations to file an Equal Accommodations Discrimination Complaint is 180 days


Division of Human and Civil Rights

Housing Intake Questionnaire

* The Statute of limitations to file a Fair Housing discrimination Complaint is 1 year from the most recent action


New Castle Kent Sussex
Division of Human and Civil Rights
Carvel State Office Bldg.
820 N. French St., 4th Floor
Wilmington, DE 19801
 Division of Human and Civil Rights
Cannon Bldg, Suite 145.
861 Silver Lake Blvd
Dover, DE 19904
 Division of Human and Civil Rights
Thurman Adams Jr. State Service Center
546 S. Bedford St.
Georgetown, DE 19947




Is the alleged discrimination continuous or on going? 
Section 1 - Complainant’s Information (This is the person completing this form)

First Name:*
Last Name:*
Address:*
City:*
State:*
ZIP:*
County:*
Email:*
Please enter at least one phone number below.
Home Phone:
Work Phone:
Cell Phone:
Section 2 - Contact Information (Someone other than yourself, we could contact in case we can’t contact you)

No alternates entered.

Section 3 - If you have an attorney, please provide their information

Firm Name:
Address:
City:
State:
ZIP:
If available, please enter attorney contact information:

No attorney entered.

Section 4 - Who do you believe discriminated against you?

Provide name/address if known.
Type of property:
Business Name:
Address:
City:
State:
ZIP:
Phone:



Respondent Information (The person(s) who engaged in discrimination)

You must enter at least one respondent

Section 5 - Witness Information (Persons who were present to see the discrimination)

No witnesses entered.

Section 6 - What happened?

Now tell us why you believe this discrimination occurred by selecting the appropriate reason from the list below?
(If you believe the discrimination occurred for more than one reason, then select all that apply.)
Hold the Ctrl key to select more than one, if necessary.


What happened to you?
Hold the Ctrl key to select more than one, if necessary.


Now that you have identified the class(s), briefly explain why you think you were discriminated against for the reason(s) listed above.
Section 7 - Confirmation and Signature

Please check the box and enter your signature to indicate confirmation this is a valid complaint.

 By selecting the checkbox and typing my name below, I am hereby electronically signing this complaint form and I further certify that the information on this form is accurate and describes what I believe was an unlawful act of discrimination.
First name/Last name
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