HUD Form 903 Complaint

Report Housing Discrimination

U.S. Department of Housing and Urban Development
Office of Fair Housing and Equal Opportunity

QUESTION 1

Why do you believe someone discriminated against you, someone you live with, or someone you sought to live with?

Choose at least one reason. You can choose more than one.

Because of race

Because of color

Because of religion

Because of national origin (including limited English proficiency)

Because of disability

Because of sex (this includes, but is not limited to, discrimination because of gender, actual or perceived gender identity or sexual orientation)

Because of familial status (this includes children under 18 years old, pregnancy or seeking legal custody)

Because of, or as a direct result of, you or someone in your household being a survivor of domestic violence, dating violence, sexual assault, or stalking (such as for having a criminal record, eviction history, or bad credit history), or because you believe another housing right under the Violence Against Women Act (VAWA) was violated (for example, your landlord did not provide an emergency transfer, you were penalized for calling 9-1-1 or seeking emergency services). VAWA protections apply regardless of sex, sexual orientation, or gender identity

Because of retaliation, intimidation, or interference related to exercising a fair housing right or a VAWA right (such as filing a complaint; testifying in a proceeding), or helping others to do so

Other reason (explain below)

QUESTION 2

Who discriminated against you?

Provide as much information as you have available. We won't contact them before speaking with you.

First name:

Last name:

Relationship to you: (e.g. landlord, lender, real estate agent):

Business name:

Street address:

Apt or unit:

City:

State:

Zip:

Phone number 1:

Phone number 2:

Email address:

More than one person or business discriminated against me. We'll collect their name(s) and contact information when we speak with you.

QUESTION 3

Where did the discrimination happen?

Provide the name and address of the building, apartment complex, or other location where the discrimination occurred. Provide as much information as you have available.

Location (for example, name of residential rental or sales property, business, or bank):

Street address:

Apt or unit:

City:

*State:

Zip:

QUESTION 4

*When did the discrimination happen?

If it happened multiple times or is still happening, provide the most recent date you experienced discrimination.

*Date(s) of Discrimination:

The alleged discrimination is continuing or ongoing or the alleged discrimination is still happening.

QUESTION 5

*What happened?

Summarize the events and why you believe you experienced housing discrimination because of race, color, national origin, religion, sex, disability, or familial status and/or a violation of your VAWA rights. For example: Were you refused an opportunity to rent or buy housing? Denied a loan? Told that housing was not available when in fact it was? Treated differently because of the presence of minor children? Denied a disability related reasonable accommodation? Evicted because of your sexual orientation? Terminated from participating in a housing-assistance program? Denied a right because of or on the basis of being a survivor of domestic violence or sexual assault? Penalized for calling 9-1-1? Treated differently or denied services by a state, local government, public housing agency, or other organization that may receive money from HUD? Describe the reasons you believe discrimination occurred, any evidence you might have and provide the names of witnesses (if any).

CONTACT INFORMATION

How can we contact you?

We'll need to contact you after we review your information. We won't release any of your personal information to the person whom you identified as discriminating against you before notifying them of a formal complaint.

Second point of contact

First name:

Last name:

Phone number:

Email address:

Relationship to you (optional)

Family member or friend
Attorney
Fair housing advocate or representative
Other (explain below)

Review and submit your complaint

Review your responses, make edits(if needed), and submit your complaint.

Why do you believe someone discriminated against you, someone you live with, or someone you sought to live with?

Because of race
Because of color
Because of religion
Because of national origin (including limited English proficiency)
Because of disability
Because of sex (this includes, but is not limited to, discrimination because of gender, actual or perceived gender identity or sexual orientation)
Because of familial status (this includes children under 18 years old, pregnancy or seeking legal custody)
Because of, or as a direct result of, you or someone in your household being a survivor of domestic violence, dating violence, sexual assault, or stalking (such as for having a criminal record, eviction history, or bad credit history), or because you believe another housing right under the Violence Against Women Act (VAWA) was violated (for example, your landlord did not provide an emergency transfer, you were penalized for calling 9-1-1 or seeking emergency services). VAWA protections apply regardless of sex, sexual orientation, or gender identity
Because of retaliation, intimidation, or interference related to exercising a fair housing right or a VAWA right (such as filing a complaint; testifying in a proceeding), or helping others to do so
Other reason (explain below)

Who discriminated against you?

First name:

Last name:

Relationship to you: (e.g. landlord, lender, real estate agent):

Street address:

Apt or unit:

Business name:

City:

State:

Zip:

Phone number 1:

Phone number 2:

Email address:

More than one person or business discriminated against me. We'll collect their name(s) and contact information when we speak with you.

Where did the discrimination happen?

Location (for example, name of residential rental or sales property, business, or bank):

Street address:

Apt or unit:

City:

*State:

Zip:

*When did the discrimination happen?

*Date(s) of Discrimination:

The alleged discrimination is continuing or ongoing or the alleged discrimination is still happening.

*What happened?

How can we contact you?

Your name and contact information

*First name:

*Last name:

Phone number:

Cell phone?

Email address(s):

Preferred contact:

Best time to call:

Preferred language(s):

Your mailing address

*Street address:

Apt or unit:

*City

*State

*Zip:

Second point of contact

First name:

Last name:

Phone number:

Email address:

Relationship to you (optional)

Family member or friend
Attorney
Fair housing advocate or representative
Other (explain below)

Exit Complaint Form Without Submit

Paperwork Reduction Act Burden Statement

The public reporting burden for this collection of information is estimated to average 0.75 hours, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to the Reports Management Officer, Paperwork Reduction Project, the Office of Information Technology, US. Department of Housing and Urban Development, Washington, DC 20410-3600. When providing comments, please refer to OMB Approval No. 2529-0011. HUD may not conduct and sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid control number.

This collection of information is required for collection of pertinent information from persons or entities who wish to file housing discrimination complaints under the Fair Housing Act of 1968, as amended. 42 U.S.C. ï¿½ 3601 et seq. The information will be used to provide HUD with sufficient information to contact aggrieved persons and notify respondents; make initial assessments regarding HUD's authority to investigate allegations of unlawful housing discrimination; and conduct administrative complaint investigations. No assurances of confidentiality are provided for this information collection.

Contact Information

Where to mail, email, or fax your claim form

Submit online at www.hud.gov/fairhousing/fileacomplaint or send your claim form to the FHEO regional office that serves the state or territory where the discrimination happened. We'll review your information and contact you a soon as possible.

FHEO Region 1 (New England)
CT, ME, MA, NH, RI, VT
Mail:
FHEO Region 1
Thomas P. O'Neill, Jr. Federal Building
10 Causeway St, Room 321
Boston, MA 02222
Email: ComplaintsOffice01@hud.gov
Fax: Call (617) 994-8300 for assistance

FHEO Region 2 (NJ, NY, Caribbean)
NJ, NY, Puerto Rico, Virgin Islands
Mail:
FHEO Region 2
U.S. Department of Housing and Urban Development
26 Federal Plaza, Room 3532
New York, NY 10278
Email: ComplaintsOffice02@hud.gov
Fax: Call (212) 542-7519 for assistance

FHEO Region 3 (Mid-Atlantic)
DE, DC, MD, PA, VA, WV
Mail:
FHEO Region 3
The Wanamaker Building
100 Penn Square East, 12th Floor
Philadelphia, PA 19107
Email: ComplaintsOffice03@hud.gov
Fax: Call (215) 861-7646 for assistance

FHEO Region 4 (Southeast)
AL, FL, GA, KY, MS, NC, SC, TN
Mail:
FHEO Region 4
77 Forsyth Street, SW
Atlanta, GA 30303
Email: ComplaintsOffice04@hud.gov
Fax: Call (404) 331-5140 for assistance

FHEO Region 5 (Upper Midwest)
IL, IN, MI, MN, OH, WI
Mail:
FHEO Region 5
Ralph H. Metcalfe Federal Building
77 West Jackson Boulevard, Rm. 2202
Chicago, IL 60604
Email: ComplaintsOffice05@hud.gov
Fax: Call (312) 913-8453 for assistance

FHEO Region 6 (South/Southwest)
AR, LA, NM, OK, TX
Mail:
FHEO Region 6
307 W. 7th Street
Suite 1000
Fort Worth, TX 76102
Email: ComplaintsOffice06@hud.gov
Fax: Call (817) 978-5900 for assistance

FHEO Region 7 (Lower Midwest)
IA, KS, MO, NE
Mail:
FHEO Region 7
Gateway Tower II
400 State Avenue, Room 200
Kansas City, KS 66101
Email: ComplaintsOffice07@hud.gov
Fax: Call (913) 551-6958 for assistance

FHEO Region 8 (Mountain West)
CO, MT, ND, SD, UT, WY
Mail:
FHEO Region 8
U.S. Department of Housing and Urban Development
1670 Broadway
Denver, CO 80202
Email: ComplaintsOffice08@hud.gov
Fax: Call (303) 672-5437 for assistance

FHEO Region 9 (West/Territory Islands)
AZ, American Samoa, CA, Guam, HI, NV
Mail:
FHEO Region 9
One Sansome St.
Suite 1200
San Francisco, CA 94104
Email: ComplaintsOffice09@hud.gov
Fax: Call (415) 489-6524 for assistance

FHEO Region 10 (Northwest)
AK, ID, OR, WA
Mail:
FHEO Region 10
Seattle Federal Office Building
900 First Avenue, Room 205
Seattle, WA 98104
Email: ComplaintsOffice10@hud.gov
Fax: Call (206) 220-5170 for assistance

Privacy Act Statement

HUD gathers information on employees, individuals applying for HUD programs, business partners, contractors and clients. The Privacy Act of 1974 established controls over what personal information is collected by the federal government and how it is used.

The Act grants rights to United States citizens and legal permanent residents. Under the Privacy Act you:

Have the right to see records about yourself; and
Can correct a record that is inaccurate, irrelevant, untimely, or incomplete.

Your housing discrimination complaint will be reviewed by a fair housing specialist to determine if it alleges acts that might violate the Fair Housing Act. The specialist will contact you for any additional information needed to complete this review. If your complaint involves a possible violation of the Fair Housing Act, the specialist will assist you in filing an official housing discrimination complaint.

OMB Control #: 2529-0011
Expiration Date: 12/31/2023

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