Report Housing Discrimination

Q1: Why do you believe someone discriminated against you, someone you live with, or someone you sought to live with?

Other Reason

Q2: 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

Address

Business name or job title:

Phone Number 1

Phone Number 2

Location Name

Location

Street Address

Apt or Unit

City

State

Zip Code

More than one person or business discriminated against me

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

Q3: 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

Street Address

City

State

Zip Code

Q4: 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:

Q5: What happened?

Summarize the events and why you believe you experienced housing discrimination because of your race, color, national origin, religion, sex, disability, or familial status and/or violation of your VAWA rights. For example: Were you refused an opportunity to rent or buy housing? Denied a loan? Treated differently because of the presence of your minor children? Told housing was not available when in fact it was? 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? Treated differently or denied services by a state, local government, public housing agency, or other programs that may receive funding from HUD? Describe the reasons you believe discrimination occurred, any evidence you might have, and provide names of witnesses (if any).

Statement

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/Mobile

Preferred Contact Method

Phone

Other

Best time to call

Morning

Afternoon

Physical Address

Street Address

Apt. or Unit

City

State

Zip Code

Mailing Address

Street Address

Apt. or Unit

City

State

Zip Code

Second point of contact

First Name

Last Name

Phone/Mobile

Relationship to you

Family member or friend

Attorney

Fair Housing Advocate

Other

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