Fair Housing Service
Intake Form
Please indicate who is completing this form.
*
Please Select
Rhonda
Charla
Carlene
Self
Other
Intake Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Adams
Douglas
Lancaster
Pottawattamie
Sarpy
Washington
Email
*
example@example.com
Number of Adults in the home
Number of Children in the home
Tenant Information
Marital Status
*
Please Select
Single
Single - Never been married
Married with Dependent(s)
Married without Dependent(s)
Divorced
Separated
Widowed
Cohabitating
Veteran
*
Please Select
Yes
No
Disabled
*
Please Select
Yes
No
Gender
*
Please Select
Female
Male
Non- Binary
Prefer not to specify
Race
*
Please Select
American Indian or Alaska Native
Asian (A)
Black or African American (B)
Multi-Racial
Native Hawaiian or Pacific Islander
White or Caucasian (W)
Other
Ethnicity
*
Please Select
Hispanic/Latino
Non-Hispanic/Non- Latino
Age Range
*
Please Select
18 to 24 Years
25 to 44 Years
45 to 64 Years
65 to 84 Years
85 and Over
Yearly Income
*
Fair Housing Concern
*
Submit
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