Report
Housing Discrimination U.S.
Department of Housing and Urban Development
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)
Other members of
my household or other people at the property experienced
discrimination. We’ll collect their name(s) and contact
information when we speak with you.
U.S.
Department of Housing and Urban Development Office of Fair Housing
and Equal Opportunity (FHEO) HUD-903.1
An
official form of the United States Government
OMB
Control #: 2529-0011 Expiration Date: 9/30/25
Office of Fair
Housing and Equal Opportunity
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 (or business name): |
Last name: |
Relationship to you: (e.g. landlord, lender, real estate agent) |
Address: |
Business name or job title: |
Phone number 1: Phone number 2: |
Email address: |
Location (for example, name of residential rental or sales property, public entity, business, or bank): |
Street address: Apt. or unit: |
City: State: ZIP: |
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?
Location
(for
example, name of residential rental or sales property, public
entity, business, or bank):
Street
address: Apt. or unit:
City: State: ZIP:
U.S.
Department of Housing and Urban Development Office of Fair Housing
and Equal Opportunity (FHEO) HUD-903.1
An
official form of the United States Government
OMB
Control #: 2529-0011 Expiration Date: 9/30/25
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: |
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).
What happened?: |
U.S. Department of Housing and Urban Development Office of Fair Housing and Equal Opportunity (FHEO) HUD-903.1
An official form of the United States Government
OMB Control #: 2529-0011 Expiration Date: 9/30/25
What happened? (continued): |
NOTE: If you need more space, attach additional pages
An official form of the United States Government
OMB Control #: 2529-0011 Expiration Date: 9/30/25
Street
Address: Apt. or unit:
City: State: Zip:
First name: Last
name:
An
official form of the United States Government
OMB
Control #: 2529-0011 Expiration Date: 9/30/25
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.
Your
name and contact information
First name:
Last name:
Phone number:
Cell phone?
Email
address(es):
Preferred
contact:
Phone
Email Other
Best time to
call:
Morning
Afternoon Preferred
language(s):
Street address:
Apt. or unit:
City:
State:
ZIP:
Your
mailing address
Second
Point of Contact
Phone number: Email
address:
Relationship
to you (optional)
Family
member or friend
Attorney
Fair
housing advocate or representative
Other
U.S.
Department of Housing and Urban Development Office of Fair Housing
and Equal Opportunity (FHEO) HUD-903.1
FORM INSTRUCTIONS
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 Five Points Plaza 40 Marietta NW St.,
16th Floor 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
U.S. Department of Housing and Urban Development Office of Fair Housing and Equal Opportunity (FHEO) HUD-903.1
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
An official form of the United States Government
OMB Control #: 2529-0011 Expiration Date: 9/30/25
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. § 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.
An official form of the United States Government
OMB Control #: 2529-0011 Expiration Date: 9/30/25
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | DI-7927 Housing Discrimination Claim Form |
Subject | Housing discrimination claim form |
Author | HUD |
File Modified | 0000-00-00 |
File Created | 2023-07-29 |