Is this form legally required?

Not universally. The form is a documentation tool; however, certain programs or contracts may require disclosure intake or specific reporting. For HUD complaints or statutory filings, follow agency guidance and applicable state rules.

Can the form be signed electronically?

Yes. Electronic signatures are legally valid under ESIGN (15 U.S.C. §7001) and UETA in most states; ensure intent, consent, attribution, and retention are documented when using e-signatures.

When should I notify HUD or a state agency?

If an internal investigation cannot resolve an alleged discriminatory act, consider HUD or state agency complaint options. Agencies have procedural rules and filing windows; consult HUD guidance or counsel to determine timing.

How long must I keep the disclosure?

Retain disclosures for the active case period plus additional years per applicable standards. If records include PHI, maintain them for six years under HIPAA (45 CFR §164.530(j)); otherwise follow organizational retention policy.

What if I discover an error after submitting?

Correct factual errors promptly and note the correction date on the record. For material changes that affect investigations, notify the reviewing authority or legal counsel to preserve transparency.

Do I need a notary or witnesses?

Not typically required for intake forms, but some jurisdictions or specific filings may require notarization or witnesses. Verify state-specific authentication requirements before relying on notarization.

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Housing Discrimination Disclosure Form

Housing Discrimination Disclosure Form

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HOUSING DISCRIMINATION DISCLOSURE FORM

This Housing Discrimination Disclosure Form (the "Disclosure") is made on Date of Disclosure: by and between Landlord Name: ("Landlord") and Applicant/Tenant Name: concerning the real property located at Property Address: .

RECITALS

WHEREAS, federal, state, and local fair housing laws prohibit discrimination in the sale, rental, financing, or advertising of dwellings on the basis of race, color, national origin, religion, sex, familial status, disability, and other protected characteristics provided by applicable law; and

WHEREAS, Landlord is required to provide prospective tenants and applicants with notice of their rights under applicable fair housing laws and to disclose practices and policies that relate to requests for reasonable accommodations, reasonable modifications, assistance animals, and other disability-related needs; and

WHEREAS, Applicant seeks to document receipt of such notices and to identify any current or anticipated accommodation or modification requests as part of the rental application or tenancy process.

NOW, THEREFORE, in consideration of the mutual covenants set forth herein and other good and valuable consideration, the parties agree as follows:

1. DEFINITIONS

For purposes of this Disclosure, "reasonable accommodation" means a change, exception, or adjustment to a rule, policy, practice, or service when necessary to afford a person with a disability equal opportunity to use and enjoy a dwelling. "Reasonable modification" means a structural change to a dwelling or common area for a person with a disability.

2. STATEMENT OF RIGHTS

Landlord affirms that Applicant has the right to be free from unlawful discrimination in housing. Landlord will not take adverse action against an applicant or tenant on the basis of any characteristic protected by applicable fair housing law. Any eligibility criteria, screening standards, or occupancy rules applied to Applicant will be applied uniformly and in compliance with all applicable nondiscrimination laws.

3. DISCLOSURE OF POLICIES AND PRACTICES

Landlord hereby discloses the following policies and practices concerning accommodations, animals, and other disability-related requests. Applicant acknowledges receipt of the following information:

Policies applicable to this property:

Landlord maintains a nondiscrimination policy and will evaluate accommodation and modification requests in accordance with applicable law.

Assistance animals and emotional support animals will be considered as reasonable accommodations when supported by appropriate documentation.

Requests for reasonable modifications to the dwelling or common areas will be reviewed and may be granted subject to applicable procedures.

4. REQUESTS FOR ACCOMMODATION OR MODIFICATION

Applicant may request a reasonable accommodation or modification by providing a written request to Landlord at the Notices address below. Landlord will engage in an interactive process as necessary to determine whether the requested accommodation or modification is reasonable and necessary, taking into account the nature of the disability, the requested change, and applicable safety and structural considerations. Landlord may request reliable written verification of disability-related need where appropriate.

If Applicant is making a request now, describe request:

5. PROTECTED CHARACTERISTICS

Applicant acknowledges that the following characteristics are protected under applicable fair housing laws. Landlord confirms that no eligibility or screening criteria will be applied in a manner that discriminates on any of these grounds:

Race Color National origin

Religion Sex Familial status

Disability Gender identity Sexual orientation

6. COMPLAINTS AND REPORTING

Applicant is advised that alleged discriminatory practices may be reported to appropriate governmental enforcement agencies under federal, state, or local laws. Landlord agrees to cooperate with any lawful investigation concerning alleged unlawful discrimination and will not retaliate against Applicant for filing a good faith complaint regarding discrimination.

7. REPRESENTATIONS AND CERTIFICATIONS

Landlord represents that the information provided in this Disclosure is true and accurate to the best of Landlord's knowledge. Applicant acknowledges receipt of this Disclosure and certifies that Applicant has been afforded the opportunity to ask questions and request additional information concerning rights and obligations under applicable fair housing laws.

Landlord representative completing this form (if other than Landlord):

8. NOTICES

Notices required under this Disclosure shall be in writing and delivered to the addresses provided below. Notice is effective upon personal delivery or three business days after deposit in the United States mail, postage prepaid, addressed to the party at the address below.

Landlord Notice Address: Applicant Notice Address:

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Disclosure shall be governed by and construed in accordance with the laws of the state in which the property is located without regard to conflict of law principles. This Disclosure constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral. If any provision of this Disclosure is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

10. AMENDMENT; WAIVER; COUNTERPARTS

No amendment to this Disclosure shall be effective unless in a writing signed by both parties. No waiver of any provision of this Disclosure shall be effective unless in writing signed by the party against whom enforcement is sought. This Disclosure may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

11. ACKNOWLEDGMENT

By signing below, Applicant acknowledges receipt of this Housing Discrimination Disclosure Form, understands the rights and protections described herein, and understands the procedure for requesting reasonable accommodations or modifications. Landlord acknowledges delivery of this Disclosure to Applicant and confirms that it will maintain policies in compliance with applicable fair housing laws.

Landlord

Printed Name:

By:

Date:

Applicant / Tenant

Printed Name:

By:

Date:

What the Housing Discrimination Disclosure Form Is and When it Applies

The Housing Discrimination Disclosure Form is a written record used to report, document, or disclose allegations, incidents, or policies related to housing discrimination. It records claimant and property details, the protected characteristic at issue, incident dates, witness information, and any remedial actions taken. Providers include landlords, property managers, housing authorities, and legal representatives; the form supports internal investigations, administrative complaints, and evidence preservation. While the Fair Housing Act and HUD enforcement govern discrimination claims, the form itself is a documentation tool and may be incorporated into leases, complaint intake processes, or regulatory filings where required.

Why clear disclosure matters for housing discrimination matters

A standardized disclosure form centralizes facts, preserves evidence, and creates an auditable record useful for internal reviews, HUD or state agency complaints, and legal proceedings. Accurate, dated disclosures reduce ambiguity about timing and parties involved and support consistent responses to allegations.

Who commonly completes or receives this form

The form is used across housing, legal, and government workflows to capture allegation details and record actions taken before escalation.

Property managers and landlords — record tenant complaints and remediation steps for lease enforcement and compliance.
Housing authorities and public agencies — intake complaints and route matters to HUD or state fair housing agencies.
Attorneys and tenant advocates — create a factual file to support investigations or litigation.

Use appropriate role-based handling and data protections when sharing the form with third parties or storing it electronically.

Essential sections to include in a professional disclosure form

A well-structured Housing Discrimination Disclosure Form groups information into discrete, searchable fields to aid investigation and record retention. Clear headings and standardized answers reduce follow-up, and supporting attachment fields let users add photos, correspondence, or witness statements.

Claimant Details

Full name, contact information, preferred language, and relationship to the property; used to verify identity and enable follow-up.

Property Details

Property address, unit number, landlord/manager name, and lease dates to tie the allegation to a specific tenancy or premise.

Allegation Summary

Concise description of the incident(s), alleged discriminatory basis, and who was involved; include dates and locations.

Witnesses & Evidence

Names and contact information for witnesses plus fields for attachments such as photos, messages, or documents supporting the claim.

Actions Taken

Record of internal actions, dates of notices or repairs, investigations performed, and any final disposition or referral to authorities.

Certification

Signature block for the reporting party and reviewer, with date and statement attesting to the accuracy of the information provided.

Core data elements required on the form

Full name: Claimant or reporter name

Contact: Phone and email

Property: Street address, unit

Date of incident: MM/DD/YYYY

Protected basis: Alleged characteristic

Signature: Signer name and date

Step-by-step process to complete the disclosure

Complete the form in a single session where possible, attach supporting materials, and route the completed form to the appropriate reviewer or agency based on your internal policy.

01

Gather facts: Collect dates, names, and supporting documents.
02

Complete form: Fill required fields and attach evidence.
03

Sign and date: Use a handwritten or valid e-signature.
04

Route record: Send to compliance, legal, or HUD as required.

How to configure the form for online intake

Configure conditional fields, attachments, and required validation to streamline intake and reduce incomplete submissions when processing disclosures online.

Field	Configuration
Signature field	Required \| e-sign enabled
Date field	MM/DD/YYYY validation
Conditional basis	Show basis options when 'discrimination alleged' checked
Attachments	Allow PDF, JPG; max 10 MB

Where completed forms are typically sent

The form may be kept internally, submitted to a local fair housing agency, or attached to a HUD or court filing depending on the escalation path chosen.

Property manager: For internal investigation and remedy
Housing authority: When public housing programs are involved
HUD office: For formal administrative complaints
Legal counsel: For litigation or regulatory guidance

Digital delivery and platform considerations

Choose a platform that preserves evidence, provides an audit trail, and supports common document formats.

File formats: Accept PDF and DOCX uploads
Integrations: Connect to case management or storage
Security: Encryption in transit and at rest

Typical timelines and processing expectations

Timelines vary by internal policy and external jurisdiction; act promptly to preserve evidence and meet administrative filing windows where they apply.

Report promptly:

Submit the form as soon as practicable after the incident to preserve facts and witnesses.

HUD filing window:

HUD complaints are typically filed promptly; consult HUD guidance for current filing timelines.

Internal review:

Complete an initial assessment within 30 days where feasible.

Investigation timeframe:

Investigations can take weeks to months depending on complexity and agency caseloads.

Retention start:

Retention begins on the date the disclosure is received or created.

Common mistakes to avoid when preparing the form

Omitting precise dates and times, which weakens timelines and investigative value.
Providing vague narrative language instead of observable facts and communications.
Failing to attach supporting documents such as messages or photos referenced in the statement.
Using inconsistent names or misspelled contact details that impede follow-up or verification.

Potential consequences of inaccurate or late disclosures

Administrative action: Agency investigations and corrective orders

Civil liability: Damages and attorney fees in private suits

Loss of funding: Program sanctions for noncompliance

Reputational harm: Public complaints can damage trust

Criminal exposure: Rare but possible where fraud is alleged

Operational cost: Increased compliance and legal expenses

Comparing eSignature providers for this disclosure form

Platform choice affects authentication, audit trails, and cost. The table compares starting price, trial availability, bulk-send capability, audit trail presence, HIPAA support, and envelope limits.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Real-world examples of using an electronic disclosure workflow

Organizations use online forms to standardize intake, preserve attachments, and record reviewer actions when responding to allegations.

Martin Properties

When a tenant reported an accessibility refusal, staff used the online form to capture dates and messages.

The record included photos and a timeline.
The standardized disclosure enabled a timely internal remedy and clear evidence for a subsequent administrative review.

Fertility Centers of Illinois

Clinic staff documented a discrimination-related accommodation request using an electronic intake form.

Attachments included medical notes.
The auditable record helped coordinate accommodation steps across departments while preserving patient privacy.

Frequently asked questions about the Housing Discrimination Disclosure Form

Answers to common questions about use, e-signatures, retention, and next steps when a disclosure is made.

Need help? Contact support

Is this form legally required?
Not universally. The form is a documentation tool; however, certain programs or contracts may require disclosure intake or specific reporting. For HUD complaints or statutory filings, follow agency guidance and applicable state rules.
Can the form be signed electronically?
Yes. Electronic signatures are legally valid under ESIGN (15 U.S.C. §7001) and UETA in most states; ensure intent, consent, attribution, and retention are documented when using e-signatures.
When should I notify HUD or a state agency?
If an internal investigation cannot resolve an alleged discriminatory act, consider HUD or state agency complaint options. Agencies have procedural rules and filing windows; consult HUD guidance or counsel to determine timing.
How long must I keep the disclosure?
Retain disclosures for the active case period plus additional years per applicable standards. If records include PHI, maintain them for six years under HIPAA (45 CFR §164.530(j)); otherwise follow organizational retention policy.
What if I discover an error after submitting?
Correct factual errors promptly and note the correction date on the record. For material changes that affect investigations, notify the reviewing authority or legal counsel to preserve transparency.
Do I need a notary or witnesses?
Not typically required for intake forms, but some jurisdictions or specific filings may require notarization or witnesses. Verify state-specific authentication requirements before relying on notarization.

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