Financial Credit Complainant Information Sheet

State of Illinois Department of Human Rights FINANCIAL CREDIT COMPLAINANT INFORMATION SHEET Office Use Only: Control No: Inv. Init. Date: Instructions: Read this entire form and all of the instructions carefully before completing. All questions should be answered. This form must be postmarked or received by IDHR within 180 days of the date of the alleged discrimination. IDHR must establish if it has the right under the law to investigate your financial credit discrimination claim. If 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 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. 1. COMPLAINANT INFORMATION: Name: City: E-Mail: Address: State: Alt. Phone No: ZIP: Phone No: Alt. Phone No: Apt No: 2. PERSONAL DATA: Please provide the following information for statistical purposes only. CHECK THE CATEGORY IN THE LIST BELOW OF NATIONAL ORIGIN OR ANCESTRY WITH WHICH YOU MOST STRONGLY IDENTIFY: Greece (C) Liberia (R) U. S. A. (U) Other East Asia (W) Haiti (T) Mexico (M) Vietnam (V) India (N) Middle East (L) Ireland (I) Pakistan (K) Date of Birth: Italy (Y) Philippines (S) Japan (J) Poland (O) Sex: Korea (A) Puerto Rico (P) Other Hispanic (H) Other African/Non-Arab (F) Other Eastern Europe (E) Other National Origin or Ancestry (Z) 3. WHO ELSE CAN WE CALL IF WE CANNOT REACH YOU: Provide the names of two persons who can contact you in the event IDHR 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: City: Name: City: Address: State: Address: State: ZIP: Phone No: ZIP: Phone No: Apt No: Apt No: 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. IDHR can investigate charges of discrimination filed against financial institutions, such as banks, credit unions, insurance companies, mortgage banking companies, or savings and loan associations. Name: City: Phone No: State: Website (if known): Address: ZIP: County: CHECK THE TYPE OF RESPONDENT THAT DISCRIMINATED AGAINST YOU IN ILLINOIS: Auto Dealership Credit Union Other: Bank Department Store Credit Card Saving & Loan Office Use Only 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, IL62704; 217-785-5100; 866-740-3953 (TTY) WEBSITE: www.illinois.gov/dhr/ CHICAGO FAX: 312-814-6251 SPRINGFIELD FAX: 217-785-5106 CIS-FC. 12/9/2015 American LegalNet, Inc. www.FormsWorkFlow.com Illinois Department of Human Rights FINANCIAL CREDIT COMPLAINANT INFORMATION SHEET 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, Pregnancy, Sexual Orientation, or Order of Protection Status. IDHR cannot investigate unfair financial credit actions 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. IDHR cannot investigate charges against the Federal Government or Federal Officials. 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 IDHR to investigate. Some common issues (harms) are: Denied of Loan; Denial of Credit Card; Modification of Service; Charging higher interest rates. Please take your time and complete all the information requested for each issue and basis alleged, so we can serve you better. Fill in a separate section for each issue and basis. A. FIRST ISSUE OF HARM OR ACTION TAKEN AGAINST YOU BY RESPONDENT: BASIS: Note: see above for the Bases IDHR can investigate. Reason given by Respondent for the action taken against you: Date of Action: Explain why you feel discriminated against because of the basis identified above: How others in your situation were treated: (Please include names). B. SECOND ISSUE OF HARM OR EMPLOYMENT ACTION TAKEN AGAINST YOU BY RESPONDENT (IF APPLICABLE): BASIS: Note: see above for the Bases IDHR can investigate. Reason given by Respondent for the action taken against you: Date of Action: Explain why you feel discriminated against because of the basis identified above: How others in your situation were treated: (Please include names). American LegalNet, Inc. www.FormsWorkFlow.com CIS-FC. 12/9/2015 Illinois Department of Human Rights FINANCIAL CREDIT COMPLAINANT INFORMATION SHEET 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? Place of Employment: Date Hired: List all other sources of income: 7. COMPLAINANT'S CURRENT EMPLOYMENT, INCOME, AND FAMILY INCOME: Job Title: Salary: Yes No Yes No If yes, when? Was employment or length of employment verified? Yes No Was Income verified? Yes No Was your residence verified? Have you ever had a garnishment, attachment, foreclosure, repossession, or judgement for unpaid bills? Yes No Yes No If yes, when? Hourly Weekly Bimonthly Monthly Annually Total Family Income: 8. WITNESS INFORMATION: Name: City: Name: City: Address: State: Address: State: ZIP: Phone No: ZIP: Phone No: Apt No: Apt No: Do you have any documents to support your claim of discrimination? Have you filed a previous charge against this respondent with IDHR? Yes Yes No No Charge Number: Yes No 9. HAVE YOU FILED A PREVIOUS CHARGE AGAINST THIS RESPONDENT WITH IDHR? Date Filed: Have you filed a c