Fill and Sign the Familial Status or National Origin Form

[Date] [Landlord’s Name] [Landlord’s Address] Re: Notice to Landlord: Violation of Fair Housing Act- Reduction or Denial of Services to Families with Children Dear : [Landlord’s Name] I am your tenant at the following premises: [Address of premises] This notice is provided to you in accordance with the provisions of the Fair Housing Act, 42 U.S.C. 3604, which provides in part, that it is unlawful: (a) To refuse to sell or rent after the making of a bona fide offer, or to refuse to negotiate for the sale or rental of, or otherwise make unavailable or deny, a dwelling to any person because of race, color, religion, sex, familial status, or national origin. (b) To discriminate against any person in the terms, conditions, or privileges of sale or rental of a dwelling, or in the provision of services or facilities in connection therewith, because of race, color, religion, sex, familial status, or national origin. This notice is provided to you because you are guilty of a Reduction or Denial of Services to Families with Children, based upon the following circumstances [describe]: Please advise how you intend to rectify this matter. Sincerely, Tenant: ______________________________________ Date: _________________ [signature] Proof of Delivery This Notice delivered to Landlord or Landlord’s authorized agent: [ ] by personal delivery [ ] certified/registered mail, return receipt requested [ ] other form of notice pursuant to Lease Agreement: Signed: ______________________________________ Date: __________________________