The Report Husing Discrimination Gorm HUD 903-1

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)

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

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:

ZIP:

State:

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, public entity, business, or bank):
Street address:

Apt. or unit:

City:

ZIP:

U.S. Department of Housing and Urban Development
Office of Fair Housing and Equal Opportunity (FHEO)
HUD-903.1

State:

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:

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).
What happened?:

NOTE: Continued on next page
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
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

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

Best time to call:

Morning

Email

Other

Afternoon Preferred language(s):

Street address:

Apt. or unit:

City:

ZIP:

State:

Your mailing address
Street Address:
City:

Apt. or unit:

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

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

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: [email protected]
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: [email protected]
Fax: Call (212) 542-7519 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: [email protected]
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: [email protected]
Fax: Call (913) 551-6958 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: [email protected]
Fax: Call (215) 861-7646 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: [email protected]
Fax: Call (303) 672-5437 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: [email protected]
Fax: Call (404) 331-5140 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: [email protected]
Fax: Call (415) 489-6524 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: [email protected]
Fax: Call (312) 913-8453 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: [email protected]
Fax: Call (206) 220-5170 for assistance

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

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.

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