Free Employment Discrimination Complaint - Kansas

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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS __________________________________________) ) __________________________________________) ) __________________________________________) (Enter above the full name of Plaintiff(s)) ) ) vs. ) ) __________________________________________) Name ) ) __________________________________________) Street and number ) ) __________________________________________) City State Zip Code ) (Enter above the full name and address of Defendant in this action - list the name and address of any additional Defendants on the back side of this sheet.) EMPLOYMENT DISCRIMINATION COMPLAINT 1. This employment discrimination lawsuit is based on (check only those that apply): ____ Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. §§ 2000e, et seq., for employment discrimination on the basis of race, color, religion, gender, or national origin. NOTE: In order to bring suit in federal district court under Title VII, you must first obtain a right-to-sue letter from the Equal Employment Opportunity Commission. Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. §§ 621, et seq., for employment discrimination on the basis of age (age 40 or older). NOTE: In order to bring suit in federal district court under the Age Discrimination in Employment Act, you must first file charges with the Equal Employment Opportunity Commission. American with Disabilities Act of 1990, as amended, 42 U.S.C. §§ 12101, et seq., 1

Case Number: _________________ (To be assigned by Clerk)

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for employment discrimination on the basis of disability. NOTE: In order to bring suit in federal district court under the American with Disabilities Act, you must first obtain a right-to-sue letter from the Equal Employment Opportunity Commission. ____ Other (Describe) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

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If you are claiming that the discriminatory conduct occurred at a different location than the address provided for Defendant, please provide the following information: ________________________________________________________________________ (Street Address) (City/County) (State) (Zip Code) When did the discrimination occur? Please give the date or time period: ________________________________________________________________________ ADMINISTRATIVE PROCEDURES

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Did you file a charge of discrimination against Defendant(s) with the Kansas State Division of Human Rights or the Kansas State Commission on Human Rights? _____Yes Date filed: _____________________________ _____ No Did you file a charge of discrimination against Defendant(s) with the Equal Employment Opportunity Commission or other federal agency? _____Yes Date filed: _____________________________ _____No Have you received a Notice of Right-to-Sue Letter? _____Yes _____ No If yes, please attach a copy of the letter to this complaint. If you are claiming age discrimination, check one of the following: _____ 60 days or more have passed since I filed my charge of age discrimination with the Equal Employment Opportunity Commission. _____ fewer than 60 days have passed since I filed my charge of age discrimination with the Equal Employment Opportunity Commission.

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NATURE OF THE CASE 8. The conduct complained of in this lawsuit involves (check only those that apply): ____ failure to hire me ____ termination of my employment ____ failure to promote me ____ failure to accommodate my disability ____ terms and conditions of my employment differ from those of similar employees ____ retaliation ____ harassment ____ reduction in wages ____ other conduct (specify): ________________________________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Did you complain about this same conduct in your charge of discrimination? _____Yes _____ No 9. I believe that I was discriminated against because of (check all that apply): ____ my race or color, which is _________________ ____ my religion, which is _________________________ ____ my national origin, which is _________________________ ____ my gender, which is ______male; ______female ____ my disability or perceived disability, which is ___________________ ____ my age (my birth date is: ____________) ____ other: _____________________________________________________________ Did you state the same reason(s) in your charge of discrimination? _____Yes _____ No 10. State here, as briefly and clearly as possible, the essential facts of your claim. Describe specifically the conduct that you believe is discriminatory and describe how each defendant is involved in the conduct. Take time to organize your statement; you may use numbered paragraphs if you find it helpful. It is not necessary to make legal arguments, or to cite cases or statutes. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3

________________________________________________________________________ (Attach additional sheets as necessary). 11. The acts set forth in paragraph 10 of this complaint: _____ are still being committed by Defendant. _____ are no longer being committed by Defendant. _____ may still be being committed by Defendant. Plaintiff: _____still works for Defendant _____no longer works for Defendant or was not hired If this is a disability-related claim, did Defendant deny a request for a reasonable accommodation? _____Yes _____ No Explain: ________________________________________________________________ _______________________________________________________________________

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REQUEST FOR RELIEF As relief from the allegations of discrimination as stated above, Plaintiff prays that the court grant the following relief to Plaintiff: (check any and all that apply) ______Defendant be directed to employ Plaintiff ______Defendant be directed to re-employ Plaintiff ______Defendant be directed to promote Plaintiff ______Defendant be directed to ___________________________________________ ______Injunctive relief (please explain): ______________________________________ ______Monetary damages (please explain): ____________________________________ ______Costs and fees involved in litigating this case ______As additional relief to make Plaintiff whole, Plaintiff seeks:_________________ ________________________________________________________________________ and such other relief as may be appropriate, including attorney's fees, if applicable.

Signed this _____ day of _________________________, 20____. ____________________________________ Signature of Plaintiff ___________________________________ Name (Print or Type) ___________________________________ Address ___________________________________ City State Zip Code ___________________________________
Telephone Number

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Telephone Number

DESIGNATION OF PLACE OF TRIAL Plaintiff designates ( Wichita, Kansas City or Topeka ), Kansas as the location for the trial in this matter. (circle one location) (check one location) ____________________________________ Signature of Plaintiff REQUEST FOR TRIAL BY JURY Plaintiff requests trial by jury ( yes or no ). . no yes (circle one) (check one) ____________________________________ Signature of Plaintiff Dated: ______________ (Rev. 8/07)

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Additional Information

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