Complaint Register Hud 958
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4U.S. Department of Housing
OMB Approval No. 2529-0043
Complaint Register
and Urban Development
(Expires 11/30/2010)
Office of Fair Housing
Under Section 3 of the Housing
and Equal Opportunity
And Urban Development Act of 1968
Name of Complainant (Person or organization)
Home Phone
Street Address
Work Phone
City, State, Zip code
Against whom is this complaint being filed?
Business Phone
Name of organization or company
Street Address
City, State, Zip code
Name and identify others (if any) who violated the law in this case
You are (check all that apply)
A. Low/Very low income
D. Section 3 business concern
B. Public housing resident
E. A representative of D
C. A representative of A or B
Complaint is against (check one or more boxes)
A. Applicant
D. Recipient
B. Sub-Recipient
E. Contractor
C. Subcontractor
F. Other (please specify_________________)
Basis for non compliance with Section 3
Denied Training
Denied Employment
Denied Contracting
What did the person you are complaining against do? (Check all that apply – provide documentation)
A. Failed to meet numerical goals, as set out in
F. Failed to incorporate the Section 3 clause in
the Section 3 regulations
Section 3 solicitations or contracts
B. Failed to ensure that its contractors and
G. Failed to train and/or employ Section 3
subcontractors comply with Section 3
residents
C. Failed to notify Section 3 residents about
H. Failed to award contracts to Section 3
training and/or employment opportunities
business concerns
D. Failed to notify Section 3 business concerns
I. Contracted with a contractor found to be in
about contracting opportunities
violation of applicable statues and/or HUD
E. Failed to notify potential contractors for
regulations
Section 3 covered projects of the requirements
J. Failed to provide preference to Section 3
of Section3
residents in training and or employment
opportunities.
K. Failed to provide preferences for Section 3
business concerns in contracting opportunities
When did the act(s) checked above occur? (Include the most recent date if several dates are involved):
Identify HUD assistance program(s). (Check all that apply)
A. PIH/DEV
D. Other PIH
G. CDBG
J. Other CPD
B. PIH/MOD
E. 202/811
H. HOME
K. Lead-based Paint
C. PIH/OPER
F. Other Housing
I. Homeless
L. Other
Page 1 of 4
form HUD-958 (11/2010)
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