FINANCIAL CREDIT INFORMATION SHEET State of Illinois Department of Human Rights PLEASE PRINT LEGIBLY Today’s Date: 1. PERSONAL INFORMATION: NAME: ADDRESS: CITY: STATE: E-MAIL: APT #: ALT. PHONE #: ZIP: PHONE #: ALT. PHONE#: 2. PERSONAL DATA: Please provide the following information for statistical purposes only: DATE OF BIRTH: SEX: CHECK THE CATEGORY IN THE LIST BELOW OF NATIONAL ORIGIN OR ANCESTRY WITH WHICH YOU MOST STRONGLY IDENTIFY: Greece = B Haiti = T India = N Ireland = I Italy = Y Japan = J Korea = A Liberia = R Mexico = M Middle East = L Pakistan = K Philippines = S Poland = O Puerto Rico = P U.S.A. = U Vietnam = V Other African/ Other Other Other Non Arab = F East Asia = W Eastern Europe = E Hispanic = H Specify: Other = Z 3. ALTERNATE CONTACT INFORMATION: Provide the names of two persons who can contact you in the event this office is unable to locate you. Make sure their mailing addresses are different from your mailing address. Your charge could be dismissed if you do not provide this information and we are unable to locate you. NAME: ADDRESS: CITY: STATE: NAME: ADDRESS: CITY: STATE: APT #: ZIP: PHONE #: APT #: ZIP: PHONE #: 4. RESPONDENT INFORMATION: Write out the full legal name of the financial institution or organization (i.e. the Respondent), that you believe discriminated against you in Illinois. NAME: ADDRESS: CITY: STATE: ZIP: COUNTY: PHONE#: CHECK THE TYPE OF RESPONDENT THAT DISCRIMINATED AGAINST YOU IN ILLINOIS: Bank Savings & Loan Credit Union Credit Card Auto Dealership Other: OFFICE USE ONLY CONTROL NUMBER: Department Store INVESTIGATOR INITIALS: 100 W. Randolph St., 10th Floor, Attn. Intake Unit, Chicago, IL 60601; 312- 814-6200; 866-740-3953 (TTY); INTERVIEWS MON.-THURS. 8:30 AM to 4:00 PM In Springfield: 222 South College, Room 101-A, Attn. Intake Unit, Springfield, IL 62704; 217-785-5100; 866-740-3953(TTY); WEBSITE: www.state.il.us/dhr/ CHICAGO FAX NO. 312-814-6251 CIS-FC Rev 5/23/11 American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL CREDIT INFORMATION SHEET Illinois Department of Human Rights 5. DESCRIPTION OF THE ISSUES AND BASES THE IDHR IS BEING REQUESTED TO INVESTIGATE: In the spaces below, please indicate each issue (harm) and basis (type of discrimination) which you would like the Department to investigate. Note: The bases (types of discrimination) which the Department can investigate are listed on page 2 of this form. Some common issues (harms) are: Denied of Loan Denial of Credit Card Modification of Service Charging Higher Interest Rates A. FIRST ISSUE OF HARM OR ACTION TAKEN AGAINST YOU BY RESPONDENT: BASIS: Note: See Page 2 for the Bases IDHR can investigate. DATE OF ACTION: REASON GIVEN BY RESPONDENT FOR THE ACTION TAKEN AGAINST YOU: EXPLAIN WHY YOU FEEL DISCRIMINATED AGAINST BECAUSE OF THE BASIS IDENTIFIED ABOVE: HOW OTHERS IN YOUR SITUATION WERE TREATED: Note: Please include names. B. SECOND ISSUE OF HARM OR ACTION TAKEN AGAINST YOU BY RESPONDENT (if applicable): BASIS: Note: See Page 2 for the Bases IDHR can investigate. DATE OF ACTION: REASON GIVEN BY RESPONDENT FOR THE ACTION TAKEN AGAINST YOU: EXPLAIN WHY YOU FEEL DISCRIMINATED AGAINST BECAUSE OF THE BASIS IDENTIFIED ABOVE: HOW OTHERS IN YOUR SITUATION WERE TREATED: Note: Please include names. 6. THE FINANCIAL INSTITUTION’S PROCEDURES: EXPLAIN YOUR UNDERSTANDING OF THE QUALIFICATIONS NECESSARY TO OBTAIN CREDIT FROM THE INSTITUTION: EXPLAIN HOW YOU MET THOSE QUALIFICATIONS: WAS A REPORT FROM A CREDIT BUREAU OBTAINED? HAVE YOU EVER FILED BANKRUPTCY? YES NO WAS EMPLOYMENT OR LENGTH OF EMPLOYMENT VERIFIED? YES NO IF YES, WHEN? YES NO WAS INCOME VERIFIED? HAVE YOU EVER HAD A GARNISHMENT, ATTACHMENT, FORECLOSURE, REPOSSESSION, OR JUDGEMENT FOR UNPAID BILLS? 7. COMPLAINANT’S CURRENT EMPLOYMENT, INCOME, AND FAMILY INCOME: PLACE OF EMPLOYMENT: JOB TITLE: PRESENT OR LAST SALARY: LIST ALL OTHER SOURCES OF INCOME: SELECT ONE: YES NO HOURLY BI-MONTHLY MONTHLY YES NO IF YES, WHEN? DATE HIRED: WEEKLY ANNUALLY TOTAL FAMILY INCOME: 8. WITNESS INFORMATION AND SUPPORTING DOCUMENTS: NAME: WAS YOUR RESIDENCE VERIFIED? PHONE: NAME: PHONE: ADDRESS: ADDRESS: CITY/STATE/ZIP CITY/STATE/ZIP Do you have any documents to support your claim of discrimination? YES 9. PREVIOUS FILINGS: Have you filed a previous charge against this respondent with IDHR? YES NO CHARGE NUMBER: CIS-FC Rev 5/23/11 DATE FILED: NO Have you filed a charge regarding this situation with any other agency or filed a complaint with the institution? YES NO WHAT AGENCY AND WHEN? 2 American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL CREDIT INFORMATION SHEET Illinois Department of Human Rights IDHR Notice of Accessibility: IDHR’s programs are accessible to persons with disabilities in compliance with the ADA and Sec. 504 of the Rehabilitation Act of 1973. A person with a disability needing an accommodation to participate in IDHR programs should contact Susan Allen, the ADA Coordinator, at 217-785-5119, 217-785-5106 (fax), 866-740-3953 (TTY) or e-mail susan.allen@illinois.gov. Instructions: Read this entire form and all the instructions carefully before completing. All questions should be answered. This form must be postmarked or received by the IDHR within 180 days of the date of the alleged discrimination. The IDHR must establish if it has the right under the law to investigate your financial credit discrimination claim. If the IDHR accepts your claim of financial credit discrimination, information will be typed on an official charge form. The charge form must be signed, notarized and returned to the IDHR in a timely manner. The form should be signed and dated below. Use additional sheets if necessary. THIS IS NOT A CHARGE. If IDHR accepts your claim, we will send you a charge form for signature. Protected classes: The IDHR can investigate charges of financial credit discrimination filed against any bank, credit union, insurance company, mortgage banking company or savings and loan association which operates or has a place of business in this State. The IDHR can only investigate charges alleging the following Bases of discrimination: Age (40 and over), Physical or Mental Disability, Retaliation (complained about unlawful discrimination, filed a prior discrimination claim, or testify at a discrimination hearing), Coercion/Aiding and Abetting (helping or forcing a person to commit unlawful discrimination based upon any of the categories listed), Race, Unfavorable Military Discharge, Marital Status, Color, Ancestry, Military Status, Religion, National Origin, Sex, Sexual Orientation, or order of protection status. The IDHR cannot investigate: unfair financial credit complaints based on: political affiliations, personality conflicts, etc., unless such actions are alleged to be for one or more of the bases (Types of Discrimination) listed above; charges against the federal government (such a charge can only be filed with the EEOC office of the agency alleged to have discriminated). NOTICE TO COMPLAINANT ON RELEASE OF IDENTITY AND PERSONAL INFORMATION The Illinois Human Rights Act (“Act”), 775 ILCS 5/1101 et seq., and Section 2520.330 of the Department’s Rules and Regulations, 56 Ill. Admin. Code, Ch. II, Section 2520.330, require a charge to contain certain information in such detail as to substantially apprise the parties of the time, place, and facts with respect to the alleged civil rights violation. Pursuant to the Department’s Rules and Regulations (2 Ill. Admin Code, Ch. X, Section 926.210), anyone who submits information to the Illinois Department of Human Rights (“IDHR”) in connection with a discrimination charge should take notice and be aware of the following: (a) All contents and files maintained by IDHR pertaining to charges shall be confidential and not subject to public disclosure. Relevant exceptions are: 1) the parties to a charge may inspect the file at any time subsequent to the written notification of substantial evidence, notice of default, or notice of dismissal, administrative closure, or approval of terms of settlement by the Human Rights Commission (“Commission”); 2) after the filing of a Complaint with the Commission or the institution of judicial proceedings involving a charge, the Director may release information pertaining to the charge if such information is requested of IDHR or if the Director finds such information newsworthy, useful in education or training, relevant to an issue before the General Assembly, or similarly appropriate for disclosure. (b) Authorized personnel within IDHR analyze information that IDHR collects. This information may include personal information. IDHR staff may need to reveal some of the personal information to individuals outside the office in order to verify facts related to the charge, or to discover new facts which will help IDHR to determine whether the law has been violated. IDHR may need to disclose to Respondent correspondence, that IDHR receives from Complainant or other sources. (c) IDHR may release the identity and personal information of the parties pursuant to a Freedom of Information Act (“FOIA”) request, a subpoena or a court order, and information submitted to or obtained by IDHR may also be revealed to persons outside of IDHR to enforce a Commission Order or a settlement agreement. In addition, if a Request for Review is filed, the Chief Legal Counsel’s decision is published in the Department’s website, which is available to the public. (d) No person is required to file a charge with IDHR and reveal personal information to IDHR; however, if a person files a charge and IDHR cannot obtain the information needed to fully investigate the allegations in the charge, IDHR may close the case. CONSENT AGREEMENT AND RELEASE I have read the above “Notice to Complainant” and I understand that: 1) In the course of investigating my charge, IDHR will reveal my identity (including my name) and my personal information to named Respondent(s) in my charge to obtain facts and evidence regarding my charge; 2) I do not have to reveal my personal information to IDHR, but IDHR may close my charge if I refuse to reveal information needed to fully investigate my charge; 3) IDHR may be required by law, subpoena, court order, and/or FOIA request to disclose my charge and information in the Department’s investigation file concerning my charge to persons outside of IDHR; 4) If I file a Request for Review, IDHR will publish the Chief Legal Counsel’s decision in the IDHR’s website, which decision will contain my name and may contain my personal information. If IDHR takes a charge based on the information provided, I consent for IDHR to disclose my identity and personal information as necessary to process and investigate my charge, and I release IDHR from any liability whatsoever concerning disclosure of my identity and any personal information I provided to IDHR or IDHR obtained in processing my charge. My signature below verifies the accuracy of the information provided herein and my consent and release as indicated above. Name (printed): _____________________________ Signature: ________________________________ Date: _________________ Note: If there is certain personal information you would like withheld, please discuss your concerns with an intake supervisor. CIS-FC Rev 5/23/11 3 American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL CREDIT INFORMATION SHEET Illinois Department of Human Rights DHR Notice to Parties Interpreters The Department provides sign language interpreters upon request. For language other than English, it is the responsibility of the nonEnglish speaking party to secure an interpreter if one is needed. The interpreter must be 18 years of age or older and able to communicate effectively in both languages. The Cooper v. Salazar injunction The Illinois Department of Human Rights (“Department”) is under a federal-court injunction that, among other things, orders the Department: “to cease permanently from relying on credibility determinations made without affording the rights of confrontation and cross-examination”. See, Cooper v. Salazar, #98 C 2930, U.S. District Court for the Northern District of Illinois, Order dated November 1, 2001, at p. 26, ¶1. Meaning of the Cooper Injunction The Department cannot assess the credibility of Complainant’s testimony, the testimony of Complainant’s witnesses or the testimony of Respondent’s representatives or the witnesses of Respondent where there is conflicting testimony. In other words, if the determination of substantial evidence turns on issues of credibility, the Department should make a finding of substantial evidence so that a trier of fact may resolve those issues of credibility. This means that if a determination of lack of substantial evidence requires the Department to make a finding of fact as to conflicting evidence, the Department will make a finding of substantial evidence so that credibility may be resolved by the Human Rights Commission at a Public Hearing or in circuit court. The Illinois Human Rights Act defines “substantial evidence” as: “evidence which a reasonable mind accepts as sufficient to support a particular conclusion and which consists of more than a mere scintilla but may be somewhat less than a preponderance”. Illinois Human Rights Act §7A102(D)(2), codified at 775 ILCS 5/7A-102(D)(2). The Meaning of Credibility The Illinois Department of Human Rights is an investigatory agency. The Department’s purpose is to gather all of the evidence from each of the parties as to whether Respondent may or may not have discriminated against the Complainant within the meaning of the Illinois Human Rights Act. The Department’s purpose is to review all of the evidence and make a determination based upon the law as to whether there is sufficient evidence of discrimination to file a complaint against the Respondent with the Illinois Human Rights Commission. The Department will not make a finding that evidence submitted by a party is either believable or not believable. Thus, the Department will not base its findings on the fact that one of the parties is not telling the truth or that one party’s evidence is not believable. If the resolution of the charge of discrimination requires believing the evidence of one party over another party, the Department will make a finding of Substantial Evidence and refer the matter to the Illinois Human Rights Commission so that a trier of fact may resolve the case. Conflicting evidence exists when there are: 1. Statements of a person with material first hand knowledge contradicted by statements of a different person with material first hand knowledge. 2. Business records contradicted by oral statements of a person with material first hand knowledge. 3. Business records of one person contradicted by business records of another person. CIS-FC Rev 5/23/11 4 American LegalNet, Inc. www.FormsWorkFlow.com