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2. Please answer the following questions, briefly explaining why you feel you have been discriminated against in housing within the city of Elgin.
4. Date:*
5. First Name*
6. Last Name*
8. Address*
10. City*
    If other than Elgin, please enter city.
11. State*
    If other than IL, please enter state.
12. Zip*
14. Phone Number:*
15. Email Address:*
17. Marital Status:*
    -- Select One --MarriedSingleDivorcedWidowed
18. If Married, Spouse Name:
20. Please list name, age and relation of people in your household. If none, enter "none".
22. What is the total family income per year?*
24. Name, address and telephone number of the person(s) whose actions you are complaining about:*
26. Person #1 named above is: *
    -- Select One --BrokerSalespersonBuilding Manager or SuperintendentBank or other LenderLandlordOther
27. Person #2 named above is:
    -- Select One --BrokerSalespersonBuilding Manager or SuperintendentBank or other LenderOther
29. If other for #1, please specify.
30. If other for #2, please specify.
32. Actions by the above person(s) about which you are complaining:*

    1. Advertising
    2. Limitations on Occupancy
    3. Refusal to rent
    4. Refusal to sell
    5. Refusal to show property
    6. Refusal to negotiate

    1. Terms and conditions of rental
    2. Terms and conditions of sale
    3. Terms and conditions of financing
    4. Terms and conditions of broker services
    5. Other
33. If other, please specify.
35. Date(s) of actions(s):*
37. Which of the following factors were involved in the above action:*

    1. Age
    2. Ancestry
    3. Color
    4. Familial Status
    5. National Origin

    1. Mental Disability
    2. Physical Disability
    3. Race
    4. Religion
    5. Sex
39. Is a federal or state subsidy involved?*

    1. Yes
    2. No
40. Does the owner live on the premises?*

    1. Yes
    2. No
42. Address of house or property:*
44. Thank you for submitting the form. We will contact you within a week.
46. If you wish to receive an email copy of this form instead of printing, please check the box below and enter your email address.
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49. Email address

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