State of Illinois HOUSING/REAL ESTATE TRANSACTION COMPLAINANT INFORMATION SHEET (For IDHR Use Only) CONTROL NUMBER: Department of Human Rights Instructions: Read this entire form and all the instructions carefully before completing. All questions should be answered. However, if you do not know the answer or if a question is not applicable, leave the question unanswered and fill out as much of the form as you can. Return the form in person, by mail or fax to IDHR's Chicago Office. You have one year from the date of the alleged discrimination to file a charge, but it's best to file as soon as possible. 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. Complainant Information: Name of Aggrieved Person(s) or Organization: Address: County: Cell Phone No.: Apt. No. City, State, ZIP E-mail Address: Telephone No. Who else can we call if we cannot reach you? First Contact's Name: Address, City, State, ZIP: Second Contact's Name: Address, City, State, ZIP: Daytime Phone: Daytime Phone: 1a. What happened to you? Check all that apply. Refused an opportunity to rent or buy housing or told housing was not available when it was. Refused a request to accommodate policies or practices or modify housing because of a disability. Discriminated against in the terms or conditions of sale, rental occupancy, or in services or facilities. Discriminated against in financing of a home or commercial property. Other (explain) Discriminated against in broker's services. Treated differently than others seeking housing. Denied a loan. Intimidated/interfered/coerced in the exercise of my housing rights. 1b. State briefly what happened. (Attach an additional page if necessary.) 2a. On what date did the last act of discrimination occur? 2b. Is the action on going? Yes No Protected classes: It is a violation of the Illinois Human Rights Act to deny a person housing rights because of any of the following protected classes: race; color; religion; sex (including sexual harassment); pregnancy, national origin; familial status (families with children under 18); disability; aiding/abetting; willful interference and coercion; military status; unfavorable military discharge; retaliation; marital status; ancestry; age (40 and over); sexual orientation (including gender identity); and order of protection status. 3. Why do you believe you are being discriminated against? For example: were you denied housing because of your race? Were you denied a mortgage loan because of your religion? Or turned down for an apartment because you have children? Were you harassed because you assisted someone in obtaining their fair housing rights? Briefly explain why you think your housing rights were denied because of any of the protected classes listed above. CONTINUED ON PAGE 2 CIS-H. 1/6/2017 100 W Randolph St, 10th Floor, Attn: Housing Intake, Chicago, IL 60601; 312-814-6229; 866-740-3953 (TTY); INTERVIEWS MON.-THURS. In Springfield: 222 South College, Room 101-A, Attn: Housing Intake, Springfield, IL 62704; 217-785-5100; 866-740-3953 (TTY) www.illinois.gov/dhr TOLL FREE: 800-662-3942 CHICAGO FAX NO. 312-814-6251 SPRINGFIELD FAX NO. 217-785-5106 American LegalNet, Inc. www.FormsWorkFlow.com Illinois Department of Human Rights HOUSING COMPLAINANT INFORMATION SHEET 4a. Who do you believe discriminated against you? Name: Address, City, State, ZIP: Phone No.: 4b. Mark the applicable box that describes the person named above: Landlord Owner Bank or Other Lender Real Estate Agent Broker Other: Check the appropriate box(es): 5a. What kind of house, rental unit or property was involved? Single family home Mobile home park Number of units on the property: Apartment building of more than 4 units Commercial space Other (specify): Owner lives on the property Public or assisted housing Vacant land 5b. What is the address of the house, rental unit, or property? Address: City, State, ZIP: Apt. No.: County: Is the property still available? Sex: How did you learn of our office? Yes No Unknown National Origin (specify): 6. We need some information for statistical purposes: Date of birth (age cases only): 7. Have you filed a charge with any other agency? If so, which agency? I have read the provided "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. 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. Print Name Signature Date CONSENT AGREEMENT AND RELEASE NOTE: If there is certain personal information you would like withheld, please discuss your concern with an Intake supervisor. American LegalNet, Inc. www.FormsWorkFlow.com CIS-H 1/6/2017 Illinois Department of Human Rights HOUSING COMPLAINANT INFORMATION SHEET 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. IDHR provides sign language interpreters upon request. A person with a disability needing an accommodation to participate in IDHR programs should contact the ADA Coordinator at 312-814-6262, 312-814-1436 (fax), 866-740-3953 (TTY) or e-mail IDHR.ADA@illinois.gov. Notice to complainant on release of identity and personal information The Illinois Human Rights Act ("Act"), 775 ILCS 5/1-101 et seq., and Section 2520.330 of IDHR'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 part