1. Please type or print clearly in dark ink. Use a separate sheet of paper if more space is needed.
2. Please attach copies of important papers concerning your complaint. Do not send originals. Please be advised that the
issues described in this complaint will be shared with the Respondent.
3. IDFPR cannot act on your behalf in a court of law or as a lawyer, give legal advice, or become involved in complaints that are
in litigation or have been litigated.
COMPLAINT TYPE:
IL486-2235 8/18 (JR)
Illinois Department of Financial and Professional Regulation
Division of Real Estate
Go to: www.idfpr.com/LicenseLookUp/LicenseLookUp.asp for a complete list of professions.
I. COMPLAINANT (Your information, unless you are submitting a complaint on behalf of another individual)
Address
City/Town
Evening Phone (Optional)
ZIP Code
Daytime Telephone NumberComplainant Name
State
Email Address
Complainant's Age (Optional*) Is Complainant Disabled? (Optional*)
60 years or older
18-59 years old
Less than 18 years old
Place check () by one of the following or provide actual age:
Yes
No
Place check () by one of the following:
II. CONTACT PERSON on behalf of Complainant (Indicate "Same" if the Contact Person is also the Complainant)
Don't Know
Contact's Address City/Town
Contact's Telephone No.Contact's Name
State ZIP Code
III. RESPONDENT (Please provide the following for the professional your complaint is against)
Business Address
City/Town
Respondent's Telephone
County of Occurrence (Optional)
Business/Professional Category (real estate broker,
appraiser, auctioneer, home inspector, community
association manager, timeshare, etc.)
Business or Professional's Name
State
Date Event Occurred
Briefl y describe your complaint:
* NOTE - Providing the complainant's age and disability status under Section I above will
better assist IDFPR in tracking complaints involving seniors and disabled individuals.
Continued, next page
years old
Respondent's email
Please Select a Complaint Type
Clear Age/Disability Check Marks
