HOUSING DISCRIMINATION COMPLAINT

COMPLAINANT INFORMATION

Complainant Name: __________________________________________________________

Date of Birth: _________________________

Street Address: _____________________________________________________________

City: ______________________________ State: _________ ZIP: _______________

Mailing Address (if different): _________________________________________________

Primary Phone: (______) ______-____________ ☐ Home ☐ Cell ☐ Work

Secondary Phone: (______) ______-____________

Email Address: _____________________________________________________________

Preferred Method of Contact: ☐ Phone ☐ Email ☐ Mail

Best Time to Reach You: _____________________________________________________

CO-COMPLAINANTS (if applicable)

RESPONDENT INFORMATION

Identify all persons or entities you believe discriminated against you.

Primary Respondent

Name (Individual/Company): ___________________________________________________

Title/Position: ______________________________________________________________

Company/Organization: _______________________________________________________

Street Address: _____________________________________________________________

City: ______________________________ State: _________ ZIP: _______________

Phone: (______) ______-____________

Email (if known): ___________________________________________________________

Type of Respondent:
☐ Individual Property Owner
☐ Property Management Company
☐ Real Estate Agent/Broker
☐ Real Estate Brokerage Firm
☐ Mortgage Lender/Bank
☐ Insurance Company
☐ Homeowners Association
☐ Condominium Association
☐ Housing Authority
☐ Government Entity
☐ Employer (housing as condition of employment)
☐ Other: _________________________

Additional Respondents

SUBJECT PROPERTY

Property Address: ___________________________________________________________

City: ______________________________ State: _________ ZIP: _______________

Property Type:
☐ Single-Family Home
☐ Duplex
☐ Apartment Building (_____ units)
☐ Condominium
☐ Townhouse
☐ Mobile Home/Manufactured Housing
☐ Cooperative Housing
☐ Public Housing
☐ Section 8/Voucher Housing
☐ Senior Housing (55+ or 62+)
☐ Other: _________________________

Housing Transaction Type:
☐ Rental
☐ Purchase/Sale
☐ Mortgage/Financing
☐ Homeowners Insurance
☐ Appraisal
☐ Other: _________________________

BASIS OF DISCRIMINATION

Protected Classes Under Federal Fair Housing Act (42 U.S.C. § 3604)

Select all that apply to your situation:

☐ RACE
Describe your race: ___________________________________________________________
Describe the discriminatory conduct based on race: _________________________________
___________________________________________________________________________

☐ COLOR
Describe: ___________________________________________________________________
___________________________________________________________________________

☐ NATIONAL ORIGIN
Country/Region of Origin: _____________________________________________________
Describe the discriminatory conduct: _____________________________________________
___________________________________________________________________________

☐ RELIGION
Religious Affiliation: __________________________________________________________
Describe the discriminatory conduct: _____________________________________________
___________________________________________________________________________

☐ SEX (includes sexual harassment, gender identity, and sexual orientation per Bostock interpretation)
Describe the discriminatory conduct: _____________________________________________
___________________________________________________________________________

☐ FAMILIAL STATUS (families with children under 18, pregnant women, those securing custody)
Number of children in household: _______ Ages: ___________________________________
Are you pregnant? ☐ Yes ☐ No
Are you in the process of obtaining custody of a child? ☐ Yes ☐ No
Describe the discriminatory conduct: _____________________________________________
___________________________________________________________________________

☐ DISABILITY/HANDICAP (physical or mental impairment substantially limiting major life activities)
Note: You are not required to disclose your specific diagnosis.
General nature of disability: ____________________________________________________
Does your disability substantially limit a major life activity? ☐ Yes ☐ No
If yes, which life activity: _____________________________________________________
Describe the discriminatory conduct: _____________________________________________
___________________________________________________________________________

Additional Protected Classes Under State Law (if applicable)

☐ Age
☐ Marital Status
☐ Sexual Orientation
☐ Gender Identity/Expression
☐ Source of Income (Section 8, SSI, etc.)
☐ Immigration/Citizenship Status
☐ Ancestry
☐ Military/Veteran Status
☐ Genetic Information
☐ Domestic Violence Victim Status
☐ Arrest/Conviction Record (where protected)
☐ Other: _________________________

TYPE OF DISCRIMINATION ALLEGED

Discriminatory Housing Practices (24 C.F.R. § 100.50)

Rental/Sale Refusal:
☐ Refused to rent housing
☐ Refused to sell housing
☐ Refused to negotiate for housing
☐ Made housing unavailable

Differential Terms/Conditions:
☐ Charged higher rent or sale price
☐ Required larger security deposit
☐ Imposed different lease terms
☐ Provided inferior housing services
☐ Applied rules differently based on protected class

Misrepresentation of Availability:
☐ Told housing was not available when it was
☐ Discouraged from applying or viewing
☐ Given false information about waiting lists

Steering:
☐ Directed toward certain neighborhoods based on protected class
☐ Directed away from certain neighborhoods based on protected class
☐ Given limited options compared to others

Blockbusting:
☐ Induced to sell based on claims about demographic changes
☐ Made profit from panic selling

Harassment/Hostile Environment:
☐ Subjected to verbal harassment
☐ Subjected to physical harassment
☐ Sexual harassment
☐ Created hostile living environment
☐ Constructive eviction due to harassment

Discriminatory Eviction:
☐ Evicted or threatened with eviction based on protected class
☐ Eviction retaliation for exercising fair housing rights

Disability-Related:
☐ Refused reasonable accommodation request
☐ Refused to permit reasonable modification
☐ Failed to design/construct accessible housing

Lending/Financing:
☐ Denied mortgage or loan
☐ Charged higher interest rate
☐ Required larger down payment
☐ Offered less favorable loan terms
☐ Redlining

Insurance:
☐ Denied homeowners/renters insurance
☐ Charged higher premiums
☐ Offered less favorable coverage

Advertising:
☐ Discriminatory statements in advertising
☐ Discriminatory preferences expressed
☐ Discriminatory symbols or images used

Retaliation:
☐ Retaliated for filing fair housing complaint
☐ Retaliated for assisting others with fair housing rights
☐ Threatened or intimidated for exercising rights

Other:
☐ Describe: ________________________________________________________________

NARRATIVE STATEMENT OF FACTS

Timeline of Events

Date discrimination first occurred: _____________________________________________

Date of most recent discriminatory act: _________________________________________

Is the discrimination ongoing? ☐ Yes ☐ No

Detailed Description

Provide a chronological account of the discriminatory conduct. Be specific about dates, times, locations, persons involved, statements made, and actions taken.

Background:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

First Incident:

Date: ______________________ Time: ________________ Location: ___________________

Persons Present: _____________________________________________________________

What Happened:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

What Was Said (quote exact words if possible):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Subsequent Incidents:

Date: ______________________ Time: ________________ Location: ___________________

Persons Present: _____________________________________________________________

What Happened:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

(Attach additional pages if necessary)

Reason You Believe Conduct Was Discriminatory

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Comparative Treatment

Did you observe or learn that persons outside your protected class(es) were treated more favorably?

☐ Yes ☐ No ☐ Unknown

If yes, describe the differential treatment:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

EVIDENCE AND DOCUMENTATION

Documents in Your Possession

☐ Rental/Lease Application
☐ Signed Lease Agreement
☐ Purchase Agreement/Contract
☐ Mortgage/Loan Application
☐ Mortgage/Loan Denial Letter
☐ Insurance Application
☐ Insurance Denial Letter
☐ Written Correspondence (letters, emails)
☐ Text Messages
☐ Social Media Posts/Messages
☐ Voicemail Messages
☐ Photographs
☐ Video Recordings
☐ Audio Recordings
☐ Advertisements
☐ Flyers or Marketing Materials
☐ Credit Reports
☐ Financial Documents
☐ Medical Documentation (disability cases)
☐ Reasonable Accommodation Request
☐ Reasonable Modification Request
☐ Eviction Notice
☐ Other: _________________________

Witnesses

DAMAGES AND HARM

Economic Damages

☐ Lost security deposit: $______________
☐ Moving expenses: $______________
☐ Temporary housing costs: $______________
☐ Lost wages (time off work): $______________
☐ Higher rent/mortgage payments: $______________
☐ Attorney fees: $______________
☐ Other out-of-pocket costs: $______________
Describe: ________________________________________________________________

Total Economic Damages: $______________

Non-Economic Damages

☐ Emotional distress
☐ Humiliation
☐ Embarrassment
☐ Loss of dignity
☐ Anxiety
☐ Depression
☐ Physical symptoms from stress
☐ Loss of housing opportunity
☐ Damage to credit
☐ Other: _________________________

Describe the impact on you and your family:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

RELIEF REQUESTED

☐ Order respondent to cease discriminatory practices
☐ Rental/sale of the housing to complainant
☐ Compensatory damages for actual losses
☐ Compensatory damages for emotional distress
☐ Punitive damages
☐ Civil penalties
☐ Reasonable accommodation/modification
☐ Change in respondent's policies and practices
☐ Fair housing training for respondent
☐ Posting of fair housing notices
☐ Reporting requirements
☐ Attorney fees and costs
☐ Other: _________________________

PRIOR COMPLAINTS OR LAWSUITS

Prior Agency Complaints

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

☐ No
☐ Yes - Complete below:

Prior Litigation

Have you filed a lawsuit regarding this matter?

☐ No
☐ Yes - Complete below:

Court: _____________________________________________________________________

Case Number: _______________________________________________________________

Attorney: __________________________________________________________________

Status: ____________________________________________________________________

CERTIFICATION

I, the undersigned, declare under penalty of perjury under the laws of the United States that:

1. The foregoing information is true and correct to the best of my knowledge, information, and belief.

2. I understand that filing a false complaint is a violation of federal law.

3. I understand that complaints must be filed within ONE YEAR of the discriminatory act with HUD, and within TWO YEARS if filing in federal court.

4. I understand that it is illegal to retaliate against anyone for filing a fair housing complaint.

5. I authorize the investigating agency to share information with relevant parties as necessary for the investigation.

_____________________________________________ _________________________
Complainant Signature Date

_____________________________________________
Printed Name

REPRESENTATIVE AUTHORIZATION (if applicable)

I authorize the following person/organization to act as my representative in this matter:

Name: _____________________________________________________________________

Organization: _______________________________________________________________

Address: ___________________________________________________________________

Phone: (______) ______-____________

Email: _____________________________________________________________________

Relationship: ☐ Attorney ☐ Fair Housing Organization ☐ Advocacy Group ☐ Family Member ☐ Other

_____________________________________________ _________________________
Complainant Signature Date

STATE-SPECIFIC NOTES

California

• State Agency: California Civil Rights Department (CRD)
• Phone: (800) 884-1684
• Website: calcivilrights.ca.gov
• Additional Protections: Sexual orientation, gender identity/expression, source of income, citizenship/immigration status, primary language, age, marital status, genetic information, military/veteran status
• Statute of Limitations: One year administrative; Two years civil court
• Notable: California's Fair Employment and Housing Act (FEHA) provides broader protections than federal law. Source of income protections include Section 8 vouchers.

Texas

• State Agency: Texas Workforce Commission Civil Rights Division
• Phone: (512) 463-2642 or (888) 452-4778
• Website: twc.texas.gov
• Filing Methods: Online, email, fax, mail, or in person
• Statute of Limitations: One year from date of discrimination
• Exemption: Owner-occupied buildings with four or fewer units may be exempt from some provisions
• Notable: Texas law (Property Code Chapter 301) generally mirrors federal protections

Florida

• State Agency: Florida Commission on Human Relations (FCHR)
• Phone: (850) 488-7082
• Email: [email protected]
• Website: fchr.myflorida.com
• Statute of Limitations: One year from alleged discriminatory act
• Protected Classes: Race, color, religion, national origin, sex, pregnancy, disability, familial status
• Important: Do not file duplicate complaints with both FCHR and HUD; choose one agency

New York

• State Agency: New York State Division of Human Rights (DHR)
• Phone: (844) 697-3471 | Fair Housing Hotline: (844) 862-8703
• Website: dhr.ny.gov
• Additional Protections: Age, sexual orientation, gender identity/expression, lawful source of income, immigration/citizenship status, military status, domestic violence victim status, arrest/conviction record, marital status
• Statute of Limitations: Three years (for incidents after February 15, 2024)
• Notable: New York Human Rights Law provides some of the broadest protections in the nation. DHR dual-files qualifying cases with HUD.

FILING OPTIONS

Federal

• Agency: U.S. Department of Housing and Urban Development (HUD)
• Online: portalapps.hud.gov/FHEO903
• Phone: 1-800-669-9777 (Voice) | 1-800-927-9275 (TTY)
• Deadline: One year from discriminatory act

Federal Court

• Option: File private lawsuit in U.S. District Court
• Deadline: Two years from discriminatory act
• Note: Does not require prior administrative filing

State Agencies

• File with your state civil rights agency (see state-specific notes above)
• Many states have work-sharing agreements with HUD

Local Agencies

• Many cities and counties have local fair housing agencies
• Check with your local government for options

ATTACHMENTS

☐ Attachment A: Additional Narrative Statement
☐ Attachment B: Copies of Documentary Evidence
☐ Attachment C: Witness Statements
☐ Attachment D: Photographs/Screenshots
☐ Attachment E: Financial Documentation
☐ Attachment F: Medical Documentation (if applicable)
☐ Attachment G: Other: _________________________

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