HUD 904-C Bases & Issues of Reports of Discrimination

Bases and Issues U.S. Department of Housing OMB Approval No. 2529-0033

of Reports of and Urban Development (Exp. 10/13/2009)

D iscrimination Office of Fair Housing and Equal Opportunity

Quarter: _______________________

Organization: _______________________________________

Note: A person may report more than one basis or issue. Number of reports of discrimination this quarter¹: _______

Basis	Number of Reports
Race	(total)
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
Color
Religion	(total)
Christian
Jewish
Muslim
Other
National Origin	(total)
Hispanic or Latino
Sex
Disability
Familial Status
Retaliation

Issue	Number of Reports
Rental
Sales
Advertising
Lending
Insurance
Reasonable Modification
Reasonable Accommodation
Design and Construction
Other

1 This is the total number of reports of discrimination received by the FHIP. A report with multiple bases or issues would be counted only once. A report from a previous quarter may be counted if a new basis or issue was added during the quarter

2. Public reporting burden for this collection of information is estimated at average 2 hours per response, including the time for searching existind data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid Office of Management and Budget (OMB) control number.

form HUD-904-C

(8/22/2006)