"*" indicates required fields Limited Service AreaAre you a Florida resident?* Yes NoEC-1-1: We are currently in beta-testing and only offer services to residents of Florida.Were you denied a request for an Emotional Support Animal reasonable accommodation?* Yes NoEC-1-2: At this time, we are only accepting new cases that involve Emotional Support Animal fair housing discrimination. About You Name ** Email **Phone **Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you live in university or on-campus housing?* Yes No I don't knowDo you receive Social Security Disability Income (SSDI) or VA income?* Yes No Case DetailStatement explaining your discrimination claim (75 words or less):*Case overview (300 words or less):*The status of my case is:* A lawsuit has been filed Notice(s) to vacate have been mailed, posted, or received Nothing has happened yet I don't know OtherOther (case status)*My case issue is:* Unjustified eviction Breach of a lease provision OtherOther (case issue)*Did the alleged ESA housing discrimination happen within the last 365 days?* Yes NoEC-3-1: The alleged discrimination must have occurred within the last year. At this time, we cannot assist you.Did the alleged ESA housing discrimination occur at a hotel, motel, RV park, or any other type of temporary housing?* Yes NoEC-3-2: Temporary shelters are not governed by the Fair Housing Act. At this time, we cannot assist you. Living SituationI have the following type of rental agreement:* Written lease on a month to month term Written lease for a year term or longer Oral agreement Not sure OtherOther (rental agreement) **Current living situation:* Living at the property Not living at the property OtherOther (living situation) **Did you receive a notice of eviction?* Yes NoPlease provide any pertinent information regarding your notice of eviction. **Current on rent?* Yes NoWhen did you last make a rent payment? **Currently owe any fines or penalties?* Yes NoPlease indicate any monies owed. ** FHA ExemptionsIs your residence an owner-occupied buildings with four or fewer units?* Yes No Not applicable I don't knowEC-4-1: This living arrangement is not governed by the Fair Housing Act. At this time, we cannot assist you.Is your residence operated by a religious organization or private club that limits occupancy to members?* Yes No Not applicable I don't knowEC-4-2: This living arrangement is not governed by the Fair Housing Act. At this time, we cannot assist you.Do you live in a single-family homes rented without a broker?* Yes No Not applicable I don't knowThe FHA doesn't apply when a single-family house is sold or rented without a broker, so long as the owner doesn't own more than three houses.EC-4-3: This living arrangement is not governed by the Fair Housing Act. At this time, we cannot assist you.Do you live in senior housing?* Yes No Not applicable I don't knowThe FHA includes "familial status" as one of its seven protected classes, which refers to the presence of at least one child under 18 living in a household. However, although the FHA bans discrimination against families with children, you may be exempt from this ban if your property qualifies as senior housing. Exempt properties include those that fit the rules of 55 and older or 62 and older communities, or those that participate in a federal, state or local senior housing program.EC-4-4: This living arrangement is not governed by the Fair Housing Act. At this time, we cannot assist you.Do you meet the qualifying standards the landlord or housing provider has for all tenants, such as having an income that is two and a half times the monthly rent?* Yes No Not applicable I don't knowEC-4-5: This living arrangement is not governed by the Fair Housing Act. At this time, we cannot assist you. Clinician/Physician (Clinical Provider)Is your Clinical Provider licensed and located in your state of residence?* Yes No I don't knowHow many therapeutic care sessions did you have within the last 12 months with this Clinical Provider?* None 1 2 or moreDo you have an ongoing treating relationship with this Clinical Provider?* Yes No I don't knowDid your landlord or housing provider communicate with your Clinicial Provider without your written permission?* Yes No I don't knowDid your landlord or housing provider ask details about your disability?* Yes No I don't know Emotional Support Animal (ESA) LetterDo you have an ESA letter verifying the need for an Emotional Support Animal?* Yes NoDoes your ESA letter state that you are a patient of the above Clinical Provider?* Yes No I don't knowDoes your ESA letter document your disability and disability-related need for an Emotional Support Animal?* Yes No I don't knowWas your ESA letter issued within the past 12 months?* Yes NoDid you purchase your ESA letter from an online vendor?* Yes No Name (or URL) of the online vendor. **Were you required to pay for any of the following: additional pet insurance, training, ESA or Service Animal Registration for a certificate, or service animal vest?* Yes NoPlease upload your ESA Letter.*Accepted file types: jpg, gif, png, doc, docx, pdf, Max. file size: 10 MB.HIPAA Compliance.We are a covered HIPAA entity, meaning we take extraordinary measures to guard your Protected Health Information. However, Attorney Members are not bound by these stringent guidelines. It is important for our Attorney Members to review your documentation, as all successful discrimination claims begin with a "perfect ESA letter." And after issuing countless letters and reviewing a wide variety of client letters, not all documents are "valid." Sharing your ESA letter of recommendation to Attorney Members requires a signed written waiver, and without both the letter and waiver, we cannot provide your case file to our Attorney Members. Please review our disclaimer and User Agreement. Reasonable Accommodation RequestYour accommodation request (i.e. waiver of no-pets-allowed, deposits, etc.)? **Do you have written proof of submitting your ESA letter to your landlord or housing provider?* Yes NoWritten proof can be an email, fax, text message, tracking receipt, etc.Did your landlord or housing provider charge pet fees or require a security deposit?* Yes No I don't knowPlease explain. **Do you have written proof of your accommodation request?* Yes NoHas your accommodation request been denied?* Yes NoHow long did it take your landlord or housing provider to deny your request?*Do you have written proof of being denied your accommodation request?* Yes NoWhat written proof do you have? **Was your accommodation request denied due to a no-pets-allowed rule?* Yes NoWas your accommodation request denied due to breed, weight, or size restrictions?* Yes NoDo you have a copy of any written rules, regulations, policies, or procedures of your landlord or housing provider which you think might be discriminatory?* Yes NoPlease upload any written rules, regulations, policies, or procedures. Drop files here or Select files Accepted file types: jpg, gif, png, doc, docx, pdf, Max. file size: 10 MB. Emotional Support AnimalPlease provide breed, size, and weight of your Emotional Support Animal(s).*How many Emotional Support Animals do you have?* None One Two Three or moreDo you live in a city or county that has a ban on certain breeds of dogs?* Yes No Not applicable I don't knowDid your landlord or housing provider require specialized training for your Emotional Support Animal?* Yes NoWhen you signed your lease, did you have a pet or Emotional Support Animal?* Yes NoDid you disclose your animal(s) at lease signing?* Yes NoHUD considers hiding the animal's existence from your landlord at the time of lease signing fraud.Please explain why you did not disclose the ESA(s). **Did your landlord or housing provider accidentally discover your Emotional Support Animal?* Yes NoDid your fail to notify your landlord or housing provider about your Emotional Support Animal?* Yes NoPlease explain why you did not disclose the ESA(s). ** Warnings, Fines, and NoticesHas your Emotional Support Animal been accused of biting, nipping, lunging at any person, or being aggressive?* Yes NoPlease explain what happened. **Has your Emotional Support Animal been accused of causing damage?* Yes NoPlease explain what happened. **Have your been warned or noticed that your Emotional Support Animal is being a nuisance?* Yes NoPlease explain what happened. **Have you been fined for your Emotional Support Animal being a nuisance?* Yes NoPlease list any fines imposed. ** Contact PreferencesDo you give us authorization to release your contact information and answers provided on this form to interested lawyers in our network?* Yes NoBy submitting your information, you acknowledge that you have read our disclaimer, User Agreement, and consent to receive email and/or SMS messaging communication from ESAD Int'l. 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