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2. 
3. Dear Complainant, Please complete the form typed or clearly legible as accurately and completely as possible.
5. The Human Relations Commission processes cases of unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age or sexual orientation. All complaints are confidential. The deadline for filing your complaint is within 180 days from the date of the unfair practice(s) or discriminatory actions(s).
7. Please be advised that you have the right to file a complaint directly with:

   Illinois Human Rights Commission
   State of Illinois Center
   100 West Randolph Street
   Suite – 100
   Chicago, Illinois 60601

9. SECTION 1: COMPLAINANT CONTACT/INFORMATION
11. Name*
12. Phone Number*
14. Email Address*
16. Home Address
18. SECTION 2: COMPLAINT INFORMATION
20. Name of company/organization where alleged event or act occurred.
22. Address of company or organization
24. Name of specific person who engaged in the discrimination, if applicable.
26. Date of alleged discrimination
27. Has the complaint been filed with any other agencies?*

    1. Yes

    1. No
29. SECTION 3: TYPE OF DISCRIMINATION
31. Date of discrimination
32. Type of discrimination*

    1. Employment
    2. Housing

    1. Public Accommodation (store, restaurant, etc.)
34. Action taken against you:

    1. Discharge
    2. Suspension

    1. Demotion (or Promotion)
    2. Hiring

    1. Harassment
    2. Failed to rent/sell

    1. Other
36. If Other, please explain below.
38. Which of the following do you believe was the cause of the action taken against you?

    1. Race
    2. Marital status
    3. Ethnic origin

    1. Gender
    2. Veteran's status
    3. Age

    1. Religion
    2. Disability

    1. Sexual orientation
    2. Other
40. If Other, please explain below.
42. Explain in detail what happened and the actions taken against you.
44. Provide details regarding how you were treated differently
46. How did you respond to the incident. List potential witnesses (name, address, and phone number)
48. The Human Relations Commission will review your complaint as quickly as possible and will contact you with any questions.
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field