(Rev. 11/29/10) IHRC003 STATE OF ILLINOIS HUMAN RIGHTS COMMISSION IN THE MATTER OF: ) ) ) ) ) Complainant(s),) ) ) ) ) ) Respondent(s).) CHARGE NO: EEOC NO: ALS NO: and COMPLAINT OF CIVIL RIGHTS VIOLATION 1) 2) My name is: _________________________________________________________________ The name of the Respondent is: __________________________________________________ ____________________________________________________________________________ 3) I filed a Charge of discrimination against the Respondent with the Illinois Department of Human Rights on _____________________. [A copy of your verified Charge must be submitted with this Complaint.] The Respondent violated the Human Rights Act in the following way: [State precisely how the Respondent violated the Human Rights Act. Give names, dates, places, etc. State which part of the Human Rights Act was violated (for example, there was discrimination based on race, religion, national origin, etc.). You must attach the copy of your Charge to this Complaint. If you wish to incorporate the Charge by reference and make it part of this Complaint, please check the following box.] 4) American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION I do hereby swear or affirm that the facts set out in this Complaint of Civil Rights Violation are true. __________________________________________ Complainant Subscribed and sworn to before me on this _______day of ___________________________, 20___. _____________________________________ Notary Public SERVICE I ask that the Commission serve a copy of the Complaint in this case on the Respondent by sending it to: _________________________________________________________________________________ (Name of person to be served) who is the ________________________________________________________________________ (Insert the official title of the person) of/for Respondent. His/Her address is: _________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ********** Please note: YOU MUST TAKE A COPY OF YOUR COMPLAINT TO THE DEPARTMENT OF HUMAN RIGHTS AND GIVE IT TO THE DEPARTMENT ON THE SAME DAY YOU FILE YOUR COMPLAINT WITH THE COMMISSION. IN CHICAGO, THE DEPARTMENT IS LOCATED ON THE TENTH FLOOR OF THE THOMPSON CENTER. American LegalNet, Inc. www.FormsWorkFlow.com