Privacy Statement: The information requested in this form will be used to investigate and process housing discrimination complaints. It may be disclosed to the U.S. Department of Justice for its use in the filing of pattern and practice suits of housing discrimination or the prosecution of the person(s) who committed the discrimination where violence is involved; and to State or local fair housing agencies that administer substantially equivalent fair housing laws for complaint processing. Though disclosure of the information is voluntary, failure to provide some or all of the requested information will result in the delay or denial of help with your housing discrimination complaint.

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PLEASE NOTE: If you are using a web browser other than Internet Explorer or Netscape Navigator, this form may NOT work correctly, either when sending information to HUD or for a verification receipt from HUD. If you are not using a compatible web browser or using a non-IBM compatible personal computer, you should call the appropriate HUD toll-free telephone number to begin a potential fair housing complaint.