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REAL PROPERTY TRANSACTION PRE-COMPLAINT QUESTIONNAIRE <br /> Page 2 of 4 <br /> 3. 1 was discriminated against because of my: (Check the applicable protected basis) <br /> ❑ Race ❑ Sex (male female) ❑ Retaliation <br /> ❑ Color ❑ Sexual Orientation (opposed discrimination) <br /> ❑ Ancestry/National Origin ❑ HIV Infection ❑ Disability (physical mental) <br /> ❑ Age ❑ Marital Status (married single) What is the disability? <br /> ❑ Religion ❑ Family Status (children pregnant) <br /> 4. 1 was discriminated against by being: (Check the adverse action that applies to you) <br /> ❑ Refused Rental ❑ Evicted <br /> ❑ Refused Sale ❑ Limited Occupancy <br /> ❑ Refused Financing ❑ Terms and Conditions <br /> ❑ Refused Accommodation ❑ Other(specify): <br /> 5. Date of the last discriminatory denial: (must be within the past 180 days) <br /> 6. Name(s)and title(s)of the person(s)who discriminated against you: <br /> 7.What reason was given to you for the adverse action: <br /> 8. How did you learn about the Hawai'i Civil Rights Commission: <br /> Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. <br /> (Rev. 10/05) <br />