_____ Race or Color
_____ National Origin
_____ Sex
_____ Age
_____ Income
_____ LEP
_____ Disability (Physical or Mental)
_____ Religion
_____ Order of Protection Status
_____ Marital Status
_____ Military Status
_____ Sexual Orientation
_____ Availability of Public Accommodation
_____ Pregnancy
_____ Unfavorable Discharge from Military Service
_____ Retaliation
_____ Sexual Harassment
_____ Ancestry
Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, on the basis of race, color, national origin, sex, age,
disability, low income and limited English proficiency (LEP), be excluded from participation in, be denied the benefits of, or be otherwise
subjected to discrimination under any program or activity receiving federal financial assistance.”
Illinois Human Rights Act, Freedom from Unlawful Discrimination, provides “to secure for all individuals within Illinois the freedom from
discrimination against any individual because of his or her race, color, religion, sex, national origin, ancestry, age, order of protection
status, marital status, physical or mental disability, military status, sexual orientation, pregnancy, or unfavorable discharge from military
service in connection with employment, real estate transactions, access to financial credit, and the availability of public accommodations.”
If you feel you have been discriminated against in services provided by the Driver Services Department of the Illinois Secretary of State*
please provide the following information to assist in processing your complaint.
* For discrimination allegations regarding employment with the Secretary of State, please consult the website at: http://www.cyberdrive
illinois.com/departments/personnel/equal_employ.html.
PLEASE PRINT CLEARLY:
Name ______________________________________________________________________________________________________
Address ____________________________________________________________________________________________________
________________________________________________________________________________________________________
City _____________________________________ State _____________________________ ZIP _________________________
Email Address _______________________________________________________________________________________________
Telephone # _________________________________________________________________________________________________
Person alleging discrimination (if different from above): _______________________________________________________________
Address of person alleging discrimination: __________________________________________________________________________
City _____________________________________ State______________________________ ZIP _________________________
Date of alleged discrimination: ___________________________________________________________________________________
Please indicate on what basis you believe discrimination occurred:
Violations under the Illinois Human Rights Act:
Printed by authority of the State of Illinois. April 2017 - 1 - Per D 230.1
Office of the Secretary of State
Department of Personnel
COMPLAINT FORM
Driver Services Department of the Illinois Secretary of State
