Form Hud-903 - Housing Discrimination Complaint Form - U.s. Department Of Housing And Urban Development

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Housing Discrimination
U.S. Department of Housing
OMB Approval No. 2529-0011
and Urban Development
Office of Fair Housing
and Equal Opportunity
Please type or print this form
Public Reporting Burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Read this entire form and all the instructions carefully before completing. All questions should be answered. However, if you do not know the answer
or if a question is not applicable, leave the question unanswered and fill out as much of the form as you can. Your complaint should be signed and dated.
Where more than one individual or organization is filing the same complaint, and all information is the same, each additional individual or organization
should complete boxes 1 and 7 of a separate complaint form and attach it to the original form. Complaints may be presented in person or mailed to the
HUD State Office covering the State where the complaint arose (see list on back of form), or any local HUD Office, or to the Office of Fair Housing and
Equal Opportunity, U.S. Department of HUD, Washington, D.C. 20410.
This section is for HUD use only.
(Check the applicable box)
Signature of HUD personnel who established Jurisdiction
Referral & Agency
Additional Info
Filing Date
Military Referral
1. Name of Aggrieved Person or Organization (last name, first name, middle initial) (Mr.,Mrs.,Miss,Ms.)
Home Phone
Business Phone
Street Address (city, county, State & zip code)
2. Against Whom is this complaint being filed? (last name, first name, middle initial)
Phone Number
Street Address (city, county, State & zip code)
Check the applicable box or boxes which describe(s) the party named above:
Supt. or Manager
Bank or Other Lender
If you named an individual above who appeared to be acting for a company in this case, check this box
and write the name and address of the company in this space:
Name and identify others (if any) you believe violated the law in this case:
3. What did the person you are complaining against do? Check all that apply and give the most recent date these act(s) occurred in block No. 6a below.
Refuse to rent, sell, or deal with you
Falsely deny housing was available
Engage in blockbusting
Discriminate in broker's services
Discriminate in the conditions or
Advertise in a discriminatory way
Discriminate in financing
Intimidated, interfered, or coerced you
terms of sale, rental occupancy, or
to keep you from the full benefit of the
in services or facilities
Federal Fair Housing Law
Other (explain)
4. Do you believe that you were discriminated against because of your race, color, religion, sex, handicap, the presence of children under 18, or a pregnant
female in the family or your national origin? Check all that apply.
Race or Color
Familial Status
National Origin
Presence of children
under 18 in the family
Asian or
Indian or
Pregnant female
5. What kind of house or property was involved? Did the owner live there?
Is the house or property What is the address of the house or property?
Single-family house
Being sold?
(street, city, county, State & zip code)
A house or building for 2, 3, or 4 families
Being rented?
A building for 5 families or more
Other, including vacant land held for
residential use (explain)
6. Summarize in your own words what happened. Use this space for a brief and concise statement of the facts.
6a.When did the act(s) checked in Item
Additional details may be submitted on an attachment.
3 occur? (Include the most recent
Note: HUD will furnish a copy of the complaint to the person or organization against whom the complaint is made.
date if several dates are involved)
7. I declare under penalty of perjury that I have read this complaint
Signature & Date
(including any attachments) and that it is true and correct.
form HUD-903 (7/2001)
Previous editions are obsolete
Page 1 of 3
ref Handbook 8024.1


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