(today’s date)

HOUSING DISCRIMINATION COMPLAINT

CASE NUMBER:		

1.	Complainant(s)

2.	Other Aggrieved Persons

3.	The following is alleged to have occurred or is about to occur:

4.	The alleged violation occurred because of:

5.	Address and location of the property in question (or if no property is involved, the city and state where the discrimination occurred):

6.	Respondent(s)

7.	The following is a brief and concise statement of the facts regarding the alleged violation:

8.	The most recent date on which the alleged discrimination occurred:

9.	Types of Federal Funds identified:

10.	The acts alleged in this complaint, if proven, may constitute a violation of the following:

Please sign and date this form:

I declare that I have read this complaint (including all attachments) and certify that it is true and correct, to the best of my knowledge.

__________________________________			___________________
(Type Complainant’s name)						Date

N O T E:	HUD WILL FURNISH A COPY OF THIS COMPLAINT TO THE PERSON OR ORGANIZATION AGAINST WHOM IT IS FILED.