Fillable State of Illinois Comptroller COMPLAINT (State of Illinois - Comptroller)

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State of Illinois Comptroller COMPLAINT (State of Illinois - Comptroller)

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Page 1 of 3
SCO-970, August 2018
COMPLAINT
Please type or print clearly below. Return completed form to: Office of Executive Inspector General, 325 West
Adams Street, Springfield, IL 62704. Alternatively, you may fax the form to our office at (217) 558-1603 or submit
the form by email to OEIG@illinoiscomptroller.gov . Our phone number is (217) 782-2103.
(Your) Contact Information
Name:*
*The OEIG accepts anonymous complaints
Age:"
Sex:
M"
F
"
Address:
Date:"
Street Address
City State Zip Code
Home Phone: Business Phone:
Other Phone: Email Address:
What is your preferred method of contact?
Are you employed by the State of Illinois, a State public
university, CTA, Me
tra, Pace, or RTA?
If yes, which agency?
Job Title:
Yes"
No
"
Is your complaint against an employee(s), agency, or someone doing
business with the
State of Illinois, CTA, Metra, Pace, or RTA?
If yes, which agency?
Yes"
No
"
Have you notified any other federal, State, or local agency of your
complaint or fi
led a lawsuit or grievance related to these matters?
Yes"
No
"
If yes, with which agency did you file a complaint?
What is the comp
laint number?
Has
your complaint been resolved?
Yes" No
"
If yes, briefly summarize the results:
Have you previously filed a complaint with the OEIG?
Yes"
No
"
If yes, please list any known OEIG case numbers:
Is this complaint related to your previously filed OEIG complaint?
Yes"
No
"
OFFICE OF EXECUTIVE INSPECTOR GENERAL
State of Illinois Comptroller
OEIG@illinoiscomptroller.gov
Page 2 of 3
SCO-970, August 2018
Please be aware that your complaint(s) may be referred to other government
agencies including the agency referred to in your complaint.
If your complaint is referred, do you consent to the release of your identity as the
complainant?
If the OEIG conducts an investigation and issues a report, do you consent to being
identified as the complainant in that report?
Yes"""
No
"
"
Yes"""
No
"
"
Subject Information (person(s) against whom you are complaining)
SUBJECT'S NAME:
Approximate Age:
M
"
F
"
Address:
Street Address
City
Agency Employed:
State
Job Title:
Zip Code
Additional Information:
SUBJECT'S NAME:
Approximate Age:
M
"
F
"
Address:
Street Address
City
Agency Employed:
State
Job Title:
Zip Code
Additional Information:
SUBJECT'S NAME:
Approximate Age:
M
"
F
"
Address:
Street Address
City
Agency Employed:
State
Job Title:
Zip Code
Additional Information:
SUBJECT'S NAME:
Approximate Age:
M
"
F
"
Address:
Street Address
City
Agency Employed:
State
Job Title:
Zip Code
Additional Information:
Page 3 of 3
SCO-970, August 2018
Complaint Information
Please summarize your complaint, including the date and time of alleged incident(s) (please attach any
documentation or other evidence in support of your complaint):
Please list other person(s) who could be a witness to the misconduct you have alleged:
Name Any identifying information (Agency, Title, Telephone Number, etc.)
Name Any identifying information (Agency, Title, Telephone Number, etc.)
Name Any identifying information (Agency, Title, Telephone Number, etc.)
Illinois law provides that the identity of any individual providing information to an Executive Inspector General
shall be kept confidential and may not be disclosed without the consent of that individual or when disclosure of the
individual's identity is otherwise required by law. 5 ILCS 430/20-90(a). Illinois law states that any person who
intentionally makes, to an Executive Inspector General, a false report alleging misconduct is guilty of a Class A
misdemeanor. 5 ILCS 430/50-5(d).
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Completed 27 January 2021

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