SOURCE OF INCOME PROTECTIONS IN CITY OR COUNTY SUPPORTED HOUSING COMPLAINT FORM

Complete this form to begin the process of filing a Source of Income Protections (SOIP) complaint with Charlotte-Mecklenburg Community Relations.

The form requests basic information that Charlotte-Mecklenburg Community Relations needs to decide whether we have jurisdiction to investigate your Source of Income Protections complaint. If you have difficulty understanding these instructions, have questions, or would like to request special accommodations, our staff members can assist you.

The Complaint Form asks questions about why you believe you were treated unfairly and how you believe this treatment violated the City of Charlotte or Mecklenburg County Source of Income Protections in City or County Supported Housing Policy.

*Charlotte-Mecklenburg Community Relations cannot investigate Source of Income Protections complaints against housing providers or developers unless they are providing city or county supported housing.*

Please take the time to answer all questions completely and accurately. The assigned SOIP investigator may request information, documentation, access to witnesses or premises or records, and other relevant articles of evidence from both parties. An Investigator collects and reviews all evidence as a neutral third party.

Once we have received your completed form, an intake staff member will contact you regarding the next steps.

Preferred Name

Pronouns

Home Phone Number

Work Phone Number

Cell Phone Number

Are you filing this complaint out for someone else?

If yes, who was denied a rental based on their lawful source of income?

Relationship to you

Contact Information of the aggrieved person

Phone Number

Is there a person or entity who will serve as your representative in this investigation e.g., an attorney, advocate, case worker?

If yes, please provide the requested information below

Phone Number

Who do you believe violated the Source of Income Protections Policy?

Organization Name

Phone Number

Were you denied housing based on your source of income?

Is there any other basis for your complaint?

If yes, please check the applicable box(es) below

Race

Color

Religion

Sex

National Origin

Familial Status

Disability

When did the most recent act of the alleged violation of Source of Income Protections occur?

Is the alleged violation still unresolved?

Why do you believe these actions were a violation of Source of Income Protections? Please provide a summary of allegations

Name and identify others, if any, who you believe violated the Source of Income Protections in City or County Supported Housing Policy:

State the sources of your income to be used toward rental payments (e.g., Housing Voucher):

Are there any witnesses to the alleged violation?

If yes, please identify them below

Phone Number

Are there any documents or other evidence of the alleged violation?

If yes, please provide a brief description of the evidence below and upload any supportive documents available. If it cannot be uploaded, how can we obtain the documents.

Supportive Documents

Click Here to Upload

Have you filed a complaint on this matter with another agency?

If yes, please provide the information requested below.

Agency Name

Date of Filing

Have you sought out help for this situation with any other agency or organization (i.e., Corporate Office, HUD, Attorney)?

If yes, please provide the information requested below.

Nam of Organization

Name of Contact within the Organization

Date of Contact

Results

If we cannot reach you directly, is there someone we can contact to help us reach you?

Phone Number

Secondary Number

Relationship to You

Acknowledgement: I want to file a complaint based on a violation of the City of Charlotte or Mecklenburg County’s Source of Income Protections in City or County Supported Housing Policies, and I authorize Charlotte-Mecklenburg Community Relations (CMCR) to look into the complaint I described above. I understand that CMCR must give the organization that I accuse of the violation information about the complaint, including my name. I also understand that CMCR can only accept complaints of Source of Income Protections against city or county supported housing providers.

Sign Here

First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.