CHARGE NUMBER AGENCY CHARGE OF DISCRIMINATION This form is affected by the Privacy Act of 1974: See Privacy act statement before completing this form. # IDHR EEOC Illinois Department of Human Rights and EEOC NAME OF COMPLAINANT (indicate Mr. Ms. Mrs.) STREET ADDRESS TELEPHONE NUMBER (include area code) CITY, STATE AND ZIP CODE DATE OF BIRTH / M / D YEAR NAMED IS THE EMPLOYER, LABOR ORGANIZATION, EMPLOYMENT AGENCY, APPRENTICESHIP COMMITTEE, STATE OR LOCAL GOVERNMENT AGENCY WHO DISCRIMINATED AGAINST ME (IF MORE THAN ONE LIST BELOW) NAME OF RESPONDENT NUMBER OF TELEPHONE (Include area code) EMPLOYEES, MEMBERS 15+ STREET ADDRESS CITY, STATE AND ZIP CODE COUNTY CAUSE OF DISCRIMINATION BASED ON: DATE OF DISCRIMINATION EARLIEST (ADEA/EPA) LATEST (ALL) CONTINUING ACTION THE PARTICULARS OF THE CHARGE ARE AS FOLLOWS: SEE ATTACHED Page 1 of I also want this charge filed with the EEOC. I will advise the agencies if I change my address or telephone number and I will cooperate fully with them in the processing of my charge in accordance with their procedures. SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ______________________, ________ . _____________________________________________________ NOTARY SIGNATURE X____________________________________________________ SIGNATURE OF COMPLAINANT NOTARY STAMP EEO-5 FORM (Rev. 2/09-INT) DATE I declare under penalty that the foregoing is true and correct I swear or affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ILLINOIS ILLINOIS DEPARTMENT OF HUMAN RIGHTS CHICAGO OFFICE _________ DEPARTMENT OF HUMAN RIGHTS 100 W. RANDOLPH ST., SUITE 10-100 CHICAGO, ILLINOIS 60601 (312) 814-6200 (217) 785-5125 TTY SPRINGFIELD OFFICE____________ DEPARTMENT OF HUMAN RIGHTS 222 S. COLLEGE, ROOM 101 SPRINGFIELD, ILLINOIS 62704 (217) 785-5100 (217) 785-5125 TTY CHARGE NO: _________________ CHARGE OF DISCRIMINATION COMPLAINANT Name Address City, State, Zip Code Telephone Number I believe that I have been personally aggrieved by a civil rights violation committed on (date/s of harm), by: RESPONDENT Name Address City, State, Zip Code County Telephone number The particulars of the alleged civil rights violation are as follows: SEE ATTACHED I, _____________________ , on oath or affirmation state that I am the Complainant herein, that I have read the foregoing charge and know the contents thereof, and that the same is true and correct to the best of my knowledge. ________________________________________ Complainant’s Signature and Date Subscribed and Sworn to Before me this ___________day of ______________________, _______ . ___________________________________ Notary Public Signature IDHR FORM #6 Rev. 2/09/INT. ________________________________ Notary Stamp American LegalNet, Inc. www.FormsWorkFlow.com Complainant: Charge Number: Page 2 of ___ American LegalNet, Inc. www.FormsWorkFlow.com