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STATE OF HAWAI'I <br /> HAWAII CIVIL RIGHTS COMMISSION <br /> �} t Princess Ke elikolani Building,830 Punchbowl Street, Room 411, Honolulu, Hawaii 96813 <br /> REAL PROPERTY TRANSACTION PRE-COMPLAINT QUESTIONNAIRE <br /> •'• r A <br /> Wjyy���q,P <br /> Please fill out this questionnaire completely.The information will be used to determine if we have jurisdiction to investigate <br /> your discrimination complaint, and to draft the charge of discrimination.You may be contacted for either a telephone or <br /> in-office interview. Please print clearly. Submit copies of documents that support your allegation of discrimination. <br /> 1. Information about you: Date: <br /> Name(Last, First, Middle Initial(s)) <br /> Address City Zip Code <br /> Home Phone Work Phone <br /> Cellular Pager <br /> Race/Ethnicity Sex <br /> Social Security Number Age&Date of Birth <br /> Names of other adults discriminated against: <br /> Names&birth dates of minor children discriminated against: <br /> Person to contact if we can't reach you: <br /> Name <br /> Address <br /> Telephone <br /> 2.Owner, Landlord, Property Manager,Association, Board, Resident Manager, <br /> Realtor, Lender,etc.that discriminated against you: <br /> Name <br /> Address City Zip Code <br /> Island ❑O'ahu ❑Kauai ❑Maui ❑Hawai'i ❑Moloka'i ❑Lana'i <br /> Telephone Type Housing&Number of Units: <br /> HCRC USE ONLY <br /> DB# Assigned to Date Assigned <br /> Interview Date Action Taken Date Action Taken <br /> Previous Editions Obsolete <br /> Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. <br /> (Rev. 10/05) <br />