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Home My WebLink AboutReal Property Transaction - Questionnaire Form STATE OF HAWAI'I HAWAII CIVIL RIGHTS COMMISSION Princess Ke elikolani Building,830 Punchbowl Street, Room 411, Honolulu, Hawaii 96813 { INSTRUCTION SHEET AND CHECKLIST FOR G•ir�iRtiA¢ REAL PROPERTY TRANSACTION PRE-COMPLAINT QUESTIONNAIRE HAWA/Y CIVIL RIGHTS COMM/SS/ON PRE-COMPLA/NT INSTRUCTIONSAND CHECKLIST REAL PROPERTY TRANSACTIONS This information is provided to help you decide whether or not your real property transaction problem can be handled by the Hawaii Civil Rights Commission (HCRC). IT IS NOT MEANT TO DISCOURAGE YOU FROM FILING A COMPLAINT. If you have difficulty understanding these instructions or have any questions, call the Hawaii Civil Rights Commission office at 586-8636(Voice), 586-8692(TDD)or 586-8655(FAX). If you are on the Neighbor Islands, call toll free by dialing: Kauai: 274-3141 (ext. 6-8636#); Maui: 984-2400(ext. 6-8636#); Hawai'i: 974-4000(ext. 6-8636#); Lana'i&Moloka'i: 1-800-468-4644(ext. 6-8636#). Enclosed is a Pre-Complaint Questionnaire. Please fill it out and return it as soon as possible.You will then be called to set up an appointment for an interview with Commission staff. If you are not called within 30 days after you return it to us, please call us.At this interview be prepared to provide the staff with information and bring any documents you have which will help us to understand your problem. IF YOU DO NOT SEND IN A COMPLETED PRE-COMPLAINT QUESTIONNAIRE YOU WILL NOT RECEIVE AN APPOINTMENT. If you have a specific problem, such as a language difficulty,that makes it hard for you to fill out the Pre-Complaint Questionnaire, please call us. WARNING--YOUR RETURN OF A COMPLETED PRE-COMPLAINT QUESTIONNAIRE DOES NOT CONSTITUTE THE FILING OF A COMPLAINT--YOU MUST STILL FILE AN OFFICIAL COMPLAINT WHICH A COMMISSION STAFF PERSON CAN ASSIST YOU WITH AFTER YOUR INTERVIEW. SECTION I We can only take complaints of ille aI discrimination. This means the unfair treatment about which you are complaining must have happened because of one or more of the reasons listed below: Your race Harassment because of your race,sex, Your sex religious beliefs, etc. Your sexual orientation Because you reported a violation of any Your religious beliefs law that CRC enforces(retaliation). Your color Because you participated in any way in Your ancestry/national origin an investigation, hearing or other Your familial status proceeding conducted by the Civil Your marital status Rights Commission. Your HIV Infection Your age Your disability The Commission does not handle any unfair treatment that is not due to one or more of the above reasons. SECTION II It is not easy to prove discrimination. In order to file a complaint,you must have information to explain why you believe the unfair treatment was because of one or more of the reasons listed in Section I.When we investigate your case,we need either direct evidence(racial slurs,sexist slurs, harassment)or we need to find evidence that you were treated differently in comparison to individuals not of your race, sex, or whatever reason(s)on which you are basing your complaint. For example, if you are Black and were evicted for being late in your rental payment,we probably cannot prove discrimination unless we find that non-Blacks were also late in their rental payments but were not evicted. In some kinds of cases,such as religious discrimination or disability status discrimination,the key evidence may take other forms. Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05) INSTRUCTION SHEET AND CHECKLIST FOR REAL PROPERTY TRANSACTION PRE-COMPLAINT QUESTIONNAIRE Page 2 of 2 SECTION III The state statute of limitations for filing complaints with the Hawaii Civil Rights Commission is 180 days after the date upon which the alleged discriminatory practice occurred or the last occurrence in a pattern of ongoing discriminatory practice. THEREFORE, IF YOU ARE COMPLAINING ABOUT SOMETHING THAT HAPPENED OVER FIVE(5)MONTHS AGO and near this statute of limitations for filing a complaint, call the Hawaii Civil Rights Commission office at 586-8636 (Voice), 586-8692 (TDD)or 586-8655(FAX). If you are on the Neighbor Islands,call toll free by dialing: Kauai: 274-3141 (ext. 6-8636#); Maui: 984-2400(ext. 6-8636#); Hawai'i: 974-4000(ext. 6-8636#); Lana'i& Moloka'i: 1-800-468-4644 (ext.6-8636#)and ask to speak to an investigator. You may also contact the U.S. Department of Housing and Urban Development(HUD),the agency that enforces the federal discrimination housing laws at 522-8182, ext. 269, 522-8193 (Text), or 522-8194(Fax). Neighbor Islanders, call toll free: 1-800-374-3247. REMEMBER., IT IS ILLEGAL FORAN OWNER ORANY07HER PERSONENGAGING INA REAL PROPERTY TRANSACTION, OR FORA REAL ESTATE BROKER OR SALESPERSON TO RETALIATEAG41NST YOU FOR FILING A COMPLAINT OR FOR CONTACTING THIS COMMISSION. Call the Hawaii Civil Rights Commission office if you have any questions. The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly. Please remember to sign and date the form before submitting it. Delivery Information Delivery by U.S. Mail or In-Person Hawaii Civil Rights Commission Princess Ke'elikolani Building, 830 Punchbowl Street, Room 411, Honolulu, Hawaii 96813 Delivery via Fax Hawaii Civil Rights Commission (808)586-8655 Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05) STATE OF HAWAI'I HAWAII CIVIL RIGHTS COMMISSION �} t Princess Ke elikolani Building,830 Punchbowl Street, Room 411, Honolulu, Hawaii 96813 REAL PROPERTY TRANSACTION PRE-COMPLAINT QUESTIONNAIRE •'• r A Wjyy��q,P Please fill out this questionnaire completely.The information will be used to determine if we have jurisdiction to investigate your discrimination complaint, and to draft the charge of discrimination.You may be contacted for either a telephone or in-office interview. Please print clearly. Submit copies of documents that support your allegation of discrimination. 1. Information about you: Date: Name(Last, First, Middle Initial(s)) Address City Zip Code Home Phone Work Phone Cellular Pager Race/Ethnicity Sex Social Security Number Age&Date of Birth Names of other adults discriminated against: Names&birth dates of minor children discriminated against: Person to contact if we can't reach you: Name Address Telephone 2.Owner, Landlord, Property Manager,Association, Board, Resident Manager, Realtor, Lender,etc.that discriminated against you: Name Address City Zip Code Island ❑O'ahu ❑Kauai ❑Maui ❑Hawai'i ❑Moloka'i ❑Lana'i Telephone Type Housing&Number of Units: HCRC USE ONLY DB# Assigned to Date Assigned Interview Date Action Taken Date Action Taken Previous Editions Obsolete Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05) REAL PROPERTY TRANSACTION PRE-COMPLAINT QUESTIONNAIRE Page 2 of 4 3. 1 was discriminated against because of my: (Check the applicable protected basis) ❑ Race ❑ Sex (male female) ❑ Retaliation ❑ Color ❑ Sexual Orientation (opposed discrimination) ❑ Ancestry/National Origin ❑ HIV Infection ❑ Disability (physical mental) ❑ Age ❑ Marital Status (married single) What is the disability? ❑ Religion ❑ Family Status (children pregnant) 4. 1 was discriminated against by being: (Check the adverse action that applies to you) ❑ Refused Rental ❑ Evicted ❑ Refused Sale ❑ Limited Occupancy ❑ Refused Financing ❑ Terms and Conditions ❑ Refused Accommodation ❑ Other(specify): 5. Date of the last discriminatory denial: (must be within the past 180 days) 6. Name(s)and title(s)of the person(s)who discriminated against you: 7.What reason was given to you for the adverse action: 8. How did you learn about the Hawai'i Civil Rights Commission: Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05) REAL PROPERTY TRANSACTION PRE-COMPLAINT QUESTIONNAIRE Page 3 of 4 Directions: Please provide a summary of the discriminatory adverse actions with the names of those who discriminated against you. Start with the earliest date and end with the last date. Use separate sheets of paper as necessary. On the next page, include the name/telephone/address of witnesses who have evidence of the discrimination. Dates of Describe the discriminatory adverse actions Discrimination (Explain why the actions were because of your protected basis) Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05) REAL PROPERTY TRANSACTION PRE-COMPLAINT QUESTIONNAIRE Page 4 of 4 Dates of Continuation of the discriminatory adverse actions Discrimination (Explain why the actions were because of your protected basis) Witnesses who have evidence of the discriminatory adverse actions Name Telephone(Home and Work) Address Closing Statement: I declare under penalty of perjury that the foregoing is true and correct. Signature Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05)