DISABILITY HOUSING DISCRIMINATION COMPLAINT

Under the Fair Housing Act

Date of Complaint: _________________________

SECTION 1: COMPLAINANT INFORMATION

Person with Disability

Full Legal Name: ____________________________________________________________

Date of Birth: _________________________

Address: __________________________________________________________________

City: ______________________________ State: _________ ZIP: _______________

Phone: (______) ______-____________

Email: _____________________________________________________________________

Preferred Communication Method:
☐ Phone ☐ Email ☐ Mail ☐ TTY/TDD ☐ Video Relay ☐ Other: _______________

Do you need any accommodations to participate in this complaint process?
☐ No
☐ Yes - Describe: _____________________________________________________________

Filing on Behalf of Another Person

☐ This complaint is filed by the person with the disability (skip to Section 2)
☐ This complaint is filed on behalf of a person with a disability

If filing on behalf of another:

Your Name: _________________________________________________________________

Your Relationship: __________________________________________________________

Your Address: ______________________________________________________________

Your Phone: (______) ______-____________

Your Email: ________________________________________________________________

Reason for Filing on Behalf:
☐ Legal guardian
☐ Authorized representative
☐ Family member with permission
☐ Advocacy organization
☐ Other: _________________________

SECTION 2: NATURE OF DISABILITY

The Fair Housing Act defines disability as a physical or mental impairment that substantially limits one or more major life activities.

IMPORTANT: You are NOT required to disclose your specific diagnosis. You only need to establish that you have a disability that substantially limits a major life activity.

Category of Disability

Physical Disability:
☐ Mobility impairment
☐ Visual impairment
☐ Hearing impairment
☐ Speech impairment
☐ Respiratory condition
☐ Cardiovascular condition
☐ Neurological condition
☐ Chronic illness
☐ Other physical condition

Mental/Psychiatric Disability:
☐ Mental health condition
☐ Cognitive impairment
☐ Learning disability
☐ Developmental disability
☐ Other mental/psychiatric condition

Other:
☐ History of disability (recovered)
☐ Perceived as having disability
☐ Associated with person who has disability

Major Life Activity Affected

Check all that apply:

☐ Walking
☐ Standing
☐ Sitting
☐ Lifting
☐ Bending
☐ Reaching
☐ Seeing
☐ Hearing
☐ Speaking
☐ Breathing
☐ Learning
☐ Reading
☐ Concentrating
☐ Thinking
☐ Communicating
☐ Caring for oneself
☐ Performing manual tasks
☐ Working
☐ Sleeping
☐ Eating
☐ Interacting with others
☐ Major bodily function (immune system, neurological, respiratory, digestive, circulatory, endocrine, reproductive, etc.)
☐ Other: _________________________

Is Your Disability Apparent/Visible?

☐ Yes, my disability is apparent
☐ No, my disability is not apparent/visible
☐ Sometimes apparent/visible

SECTION 3: RESPONDENT INFORMATION

Primary Respondent

Name (Individual or Company): _________________________________________________

Title/Position: ______________________________________________________________

Company/Property Name: _____________________________________________________

Address: __________________________________________________________________

City: ______________________________ State: _________ ZIP: _______________

Phone: (______) ______-____________

Email: _____________________________________________________________________

Type of Respondent:
☐ Property Owner
☐ Property Manager
☐ Leasing Agent
☐ Real Estate Agent/Broker
☐ Homeowners Association
☐ Condominium Association
☐ Public Housing Authority
☐ Mortgage Lender
☐ Insurance Company
☐ Architect/Builder
☐ Other: _________________________

Type of Housing:
☐ Private rental housing
☐ Private sale housing
☐ Public housing
☐ Section 8/HCV housing
☐ Project-based Section 8
☐ Other HUD-assisted housing
☐ Condominium/HOA

Additional Respondents

SECTION 4: PROPERTY INFORMATION

Property Address: ___________________________________________________________

Unit Number: ________________

City: ______________________________ State: _________ ZIP: _______________

Property Type:
☐ Single-Family Home
☐ Apartment Building (_______ units)
☐ Condominium
☐ Townhouse
☐ Mobile/Manufactured Home
☐ Public Housing
☐ Subsidized Housing

Year Built (if known): _____________

Is this property covered by:
☐ Fair Housing Act (most housing)
☐ Section 504 (federally funded housing)
☐ ADA (public accommodations in housing complexes)

SECTION 5: TYPE OF DISCRIMINATION

A. Refusal to Rent, Sell, or Negotiate

☐ Refused to rent or sell because of disability
☐ Refused to negotiate because of disability
☐ Told housing was unavailable when it was available
☐ Discouraged from applying because of disability
☐ Application denied because of disability
☐ Denied housing because of use of assistance animal
☐ Denied housing because of use of mobility device
☐ Other: _________________________

B. Discriminatory Terms, Conditions, or Privileges

☐ Charged higher rent because of disability
☐ Required larger security deposit because of disability
☐ Required additional fees for assistance animal
☐ Imposed more restrictive lease terms
☐ Denied access to amenities
☐ Provided inferior services
☐ Other: _________________________

C. Reasonable Accommodation Denial

☐ Denied request for reasonable accommodation
☐ Failed to respond to accommodation request
☐ Unreasonably delayed response to accommodation request
☐ Required unnecessary documentation
☐ Required disclosure of specific diagnosis
☐ Imposed conditions on accommodation

Type of accommodation requested:
☐ Assistance animal (service animal, emotional support animal)
☐ Reserved parking space
☐ Change in rent payment date
☐ Exception to policy/rule
☐ Transfer to accessible unit
☐ Communication accommodation
☐ Caregiver/aide access
☐ Other: _________________________

Date accommodation requested: _________________________

Date of denial/response: _________________________

D. Reasonable Modification Denial

☐ Denied request to make reasonable modification
☐ Refused to permit modification at tenant's expense
☐ Required unnecessary restoration provisions
☐ Required excessive escrow deposit
☐ Failed to permit modification to common areas

Type of modification requested:
☐ Grab bars
☐ Ramp
☐ Widened doorways
☐ Roll-in shower
☐ Lowered counters/cabinets
☐ Accessible parking space
☐ Visual/audible alerts
☐ Other: _________________________

Date modification requested: _________________________

Date of denial/response: _________________________

E. Failure to Design/Construct Accessible Housing

Applies to buildings with 4+ units built for first occupancy after March 13, 1991

☐ No accessible entrance
☐ Common areas not accessible
☐ Doorways not wide enough for wheelchair
☐ No accessible route through dwelling
☐ Light switches/outlets not in accessible locations
☐ Bathroom walls not reinforced for grab bars
☐ Kitchen/bathroom not usable by wheelchair user
☐ Other accessibility deficiency: _________________________

F. Harassment/Hostile Environment

☐ Verbal harassment based on disability
☐ Threats or intimidation
☐ Unwanted questions about disability
☐ Ridicule or mockery
☐ Interference with use of assistance animal
☐ Creation of barriers to accessibility
☐ Other: _________________________

G. Eviction/Termination

☐ Evicted because of disability
☐ Evicted because of assistance animal
☐ Lease non-renewed because of disability
☐ Threatened with eviction because of disability
☐ Evicted for disability-related behavior that could have been accommodated
☐ Constructive eviction due to harassment or denial of accommodations

H. Retaliation

☐ Retaliated for requesting accommodation/modification
☐ Retaliated for filing fair housing complaint
☐ Retaliated for assisting others with fair housing rights
☐ Retaliated for opposing discriminatory practices

I. Other Discrimination

☐ Discriminatory statements about disability
☐ Discriminatory advertising
☐ Steering based on disability
☐ Insurance discrimination
☐ Lending discrimination
☐ Other: _________________________

SECTION 6: NARRATIVE STATEMENT

Timeline

Date of first contact with respondent: _________________________

Date discrimination first occurred: _________________________

Date of most recent discriminatory act: _________________________

Is the discrimination ongoing? ☐ Yes ☐ No

Detailed Description of Events

Provide a chronological account of what happened. Include specific dates, times, persons involved, statements made (exact quotes when possible), and actions taken.

Background (how you came to seek this housing):

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

First Incident:

Date: ___________________ Time: ___________________ Location: ___________________

Person(s) Involved: ____________________________________________________________

What Happened:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

What Was Said (exact words if possible):

___________________________________________________________________________

___________________________________________________________________________

Subsequent Incidents:

Date: ___________________ Description: __________________________________________

___________________________________________________________________________

___________________________________________________________________________

Date: ___________________ Description: __________________________________________

___________________________________________________________________________

___________________________________________________________________________

(Attach additional pages as needed)

For Accommodation/Modification Denials

Did you make your request in writing? ☐ Yes ☐ No

If yes, attach a copy of your request.

Did respondent request verification of disability? ☐ Yes ☐ No

If yes, did you provide verification? ☐ Yes ☐ No

What reason did respondent give for denial?

___________________________________________________________________________

___________________________________________________________________________

Did respondent propose alternative accommodations? ☐ Yes ☐ No

If yes, describe: _____________________________________________________________

SECTION 7: COMPARATIVE TREATMENT

Were you treated differently than persons without disabilities?

☐ Yes ☐ No ☐ Unknown

If yes, describe:

___________________________________________________________________________

___________________________________________________________________________

Do you know of tenants/applicants without disabilities who were:

☐ Approved for housing
☐ Not required to provide additional documentation
☐ Not charged extra fees
☐ Allowed to have pets (while you were denied assistance animal)
☐ Given exceptions to policies
☐ Other: _________________________

Describe:

___________________________________________________________________________

___________________________________________________________________________

SECTION 8: EVIDENCE AND DOCUMENTATION

Documents in Your Possession

☐ Rental/Purchase Application
☐ Lease Agreement
☐ Denial Letter
☐ Reasonable Accommodation Request
☐ Reasonable Modification Request
☐ Healthcare Provider Verification Letter
☐ Respondent's Response/Denial
☐ Written Communications (letters, emails, texts)
☐ Voicemail Messages
☐ Property Rules/Regulations
☐ Photographs of Property/Barriers
☐ Video/Audio Recordings
☐ Eviction Notice
☐ Medical Bills/Documentation
☐ Other: _________________________

Witnesses

SECTION 9: DAMAGES AND HARM

Economic Damages

Non-Economic Damages

☐ Emotional distress
☐ Humiliation
☐ Embarrassment
☐ Anxiety
☐ Depression
☐ Exacerbation of disability symptoms
☐ Physical symptoms from stress
☐ Loss of dignity
☐ Loss of independence
☐ Isolation
☐ Other: _________________________

Describe the impact on your life:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

SECTION 10: ACCESSIBILITY COMPLIANCE (If Applicable)

For buildings with 4+ units first occupied after March 13, 1991

Design and Construction Requirements

Ground Floor Units (or all units if elevator building):

☐ Accessible building entrance on accessible route
☐ Accessible common and public use areas
☐ Doors wide enough for wheelchair passage (32" clear)
☐ Accessible route through dwelling unit
☐ Light switches, electrical outlets, thermostats in accessible locations
☐ Reinforced bathroom walls for later grab bar installation
☐ Kitchens and bathrooms usable by person in wheelchair

Which requirements are not met?

___________________________________________________________________________

___________________________________________________________________________

Have you reported accessibility issues to:

☐ Building management
☐ Local building department
☐ HUD
☐ State accessibility compliance office
☐ None of the above

SECTION 11: PRIOR COMPLAINTS

Agency Complaints

Have you filed a complaint about this matter with any other agency?

☐ No
☐ Yes

Lawsuits

Have you filed a lawsuit regarding this matter?

☐ No
☐ Yes

Court: _____________________________________________________________________

Case Number: _______________________________________________________________

Status: ____________________________________________________________________

SECTION 12: RELIEF REQUESTED

☐ Order respondent to stop discriminatory practices
☐ Grant reasonable accommodation
☐ Permit reasonable modification
☐ Provide accessible housing
☐ Compensatory damages for actual monetary losses: $_______________
☐ Compensatory damages for emotional distress
☐ Civil penalties
☐ Punitive damages
☐ Make property accessible/remove barriers
☐ Change policies and practices
☐ Fair housing training for respondent/staff
☐ Posting of fair housing notices
☐ Monitoring and reporting requirements
☐ Attorney fees and costs
☐ Other: _________________________

SECTION 13: CERTIFICATION

I certify under penalty of perjury that:

1. The information in this complaint is true and correct to the best of my knowledge.

2. I understand that complaints must be filed with HUD within ONE YEAR of the discriminatory act.

3. I understand that I may file a lawsuit within TWO YEARS.

4. I understand that retaliation against me for filing this complaint is illegal.

5. I authorize the investigating agency to share necessary information with respondent.

_____________________________________________ _________________________
Complainant Signature Date

_____________________________________________
Printed Name

STATE-SPECIFIC NOTES

California

State Agency: California Civil Rights Department (CRD)
Phone: (800) 884-1684
Website: calcivilrights.ca.gov

State Law: Fair Employment and Housing Act (FEHA)

Additional Protections:
- Broader definition of disability than federal law
- Medical condition is separately protected
- Genetic information protected
- Stronger requirements for interactive process in accommodations
- Source of income protections benefit disabled persons receiving SSI/SSDI

Notable:
- California requires "timely, good faith, interactive process" for accommodations
- State law may cover smaller housing providers exempt under federal law

Texas

State Agency: Texas Workforce Commission Civil Rights Division
Phone: (512) 463-2642
Website: twc.texas.gov

State Law: Texas Fair Housing Act, Property Code Chapter 301

Protections: Mirrors federal Fair Housing Act disability protections

Filing:
- File within one year of discrimination
- Can file online, by mail, fax, or email

Notable:
- Texas follows federal standards for disability discrimination
- Some exemptions may apply to small landlords

Florida

State Agency: Florida Commission on Human Relations (FCHR)
Phone: (850) 488-7082
Website: fchr.myflorida.com

State Law: Florida Fair Housing Act, Chapter 760

Protections: Disability is a protected class under Florida law

Notable:
- File within one year of alleged discrimination
- Do not file with both FCHR and HUD
- Florida has significant condo/HOA communities where accommodation issues arise

New York

State Agency: New York State Division of Human Rights (DHR)
Phone: (844) 697-3471
Website: dhr.ny.gov

State Law: New York Human Rights Law

Additional Protections:
- Broader definition of disability
- Protects persons with HIV/AIDS explicitly
- Protects based on genetic predisposition
- Three-year statute of limitations (incidents after February 15, 2024)

Notable:
- NYC Human Rights Law provides even broader protections
- Strong tenant protections for disabled tenants in rent-regulated housing
- Source of income protections help disabled persons with housing vouchers

LEGAL BACKGROUND: DISABILITY DISCRIMINATION

Definition of Disability

Under the Fair Housing Act, "handicap" (disability) means:
1. A physical or mental impairment that substantially limits one or more major life activities
2. A record of such impairment
3. Being regarded as having such an impairment

What is Protected?

• Refusing to rent/sell because of disability
• Discriminatory terms, conditions, or privileges
• Failure to make reasonable accommodations
• Failure to permit reasonable modifications
• Failure to design/construct accessible housing
• Harassment based on disability
• Retaliation

Reasonable Accommodations

A change in rules, policies, practices, or services that may be necessary to afford a person with a disability equal opportunity to use and enjoy a dwelling.

Examples: Assistance animals, reserved parking, policy exceptions

Reasonable Modifications

Structural changes to the premises that may be necessary to afford full enjoyment of the dwelling.

Examples: Grab bars, ramps, widened doorways

Private housing: Tenant pays
Federally funded housing: Landlord pays

Design and Construction Requirements

Buildings with 4+ units built after March 13, 1991 must meet accessibility requirements in ground floor units (or all units if elevator building).

FILING INFORMATION

Federal Filing

Online: portalapps.hud.gov/FHEO903
Phone: 1-800-669-9777 (Voice) | 1-800-927-9275 (TTY)

Deadlines

• HUD Complaint: One year from discriminatory act
• Federal Court: Two years from discriminatory act

Resources

• HUD Office of Fair Housing: hud.gov/fairhousing
• National Fair Housing Alliance: nationalfairhousing.org
• Disability Rights Organizations in your state

This template is provided for informational purposes only and does not constitute legal advice.