State of Illinois Department of Human Rights HOUSING/REAL ESTATE TRANSACTIONS COMPLAINANT INFORMATION SHEET See Pages 2 and 3 for Instructions, Notice of Accessibility, and Notices to Complainant. Name of Aggrieved Person(s) or Organization: For IDHR Use Only Control Number: Telephone Number: Cell Phone Number: E-Mail Address: Address Apt. No. County City, State, ZIP Who else can we call if we cannot reach you? First Contact’s Name: Daytime Phone: Address/City/State/ZIP: Second Contact’s Name: Daytime Phone: Address/City/State/ZIP: 1a. What happened to you? Check all that apply. Refused an opportunity to rent or buy housing or told that housing was not available when it was? Denied a loan? 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? Discriminated against in broker’s services? Treated differently from others seeking housing? Intimidated/interfered/coerced in the exercise of your housing rights? Other (explain) 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 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 the protected classes listed on page 2. 4a. Who do you believe discriminated against you? Name: Address/City/State/Zip Code: 4b. Mark the applicable box that describes the person named above: Landlord Owner Bank or Other Lender Real Estate Agent Phone No.: Broker Other: 4c. If the person named was acting for a company, write the name and address of the company here: Name: Address/City/State/Zip Code: 5a. What kind of house, rental unit or property was involved? Check the appropriate box(es): single family home apartment building of more than 4 units owner lives on the property public or assisted housing commercial space vacant land or other (specify): # of units on the property: mobile home park 5b. What is the address of the house, rental unit, or property? Is the property still available? Yes No Unknown Address: Apt. No. City/State/Zip Code: County: 6a.Sex 6b.Date of birth: (age cases only) 6c.National Origin (specify): We need some information for statistical purposes: 6d. How did you learn of our office? 7. Have you filed a charge with any other agency? If so, which agency? CONTINUED ON PAGE 2 100 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); WEBSITE: www.state.il.us/dhr/fh TOLL FREE: 800-662-3942 CHICAGO FAX NO. 312-814-6251 CIS-HSG Rev 5/23/11 American LegalNet, Inc. www.FormsWorkFlow.com HOUSING/REAL ESTATE TRANSACTIONS COMPLAINANT INFORMATION SHEET Page 2 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 the ADA Coordinator at 217-785-5119 or 866-740-3953 (TTY). 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. 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) •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. 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 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 a housing or intake supervisor. American LegalNet, Inc. www.FormsWorkFlow.com HOUSING/REAL ESTATE TRANSACTIONS COMPLAINANT INFORMATION SHEET IDHR NOTICE TO PARTIES ON CREDIBILITY (11/21/07) Page 3 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. American LegalNet, Inc. www.FormsWorkFlow.com