Source of Income Discrimination Form

It is illegal in New York State for any owner, managing agent, broker or any other representative to refuse to rent, sell, or lease housing to any person based on their source of income with certain, limited exceptions. The law prohibits denying any application for housing based on source of income or setting different terms or conditions because of your source of income. It also prohibits advertising that certain forms of income, such as Section 8 vouchers, are not accepted.  

Click here for a more detailed explanation and examples of source of income discrimination.

Regional Office
Contact information
(ex:999-999-9999 or 999-999-9999 x9999)
Contact information for person who experienced discrimination
If Yes
What is the address of the property that you were seeking to rent or buy?
Communication Method Details
If Verbally – in person

Do you have any information about the person with whom you spoke?

If Verbally – over the phone

Do you have contact information for the person you corresponded with?

If in an email or other correspondence

Do you have any information about the person with whom you spoke?

If saw discriminatory advertisement or apartment listing
If in a newspaper, or other printed publication
If on a website
Please provide any other information that you think is relevant:

Attach Documents:

  • Max file size upload is 25 Mega Bytes (MB).
Attachment 1
Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp txt rtf pdf doc docx ppt pptx xls xlsx.