Free Employment Discrimination Form - 42 U.S.C. § 2000e, 29 U.S.C. § 621, 42 U.S.C. § 12112 - Florida

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION

EMPLOYMENT DISCRIMINATION COMPLAINT FORM
TO BE USED BY PRO SE LITIGANTS IN ACTIONS FILED UNDER 42 U.S.C. § 2000e, et seq., (Title VII of the Civil Rights Act) 29 U.S.C. § 621, et seq., (Age Discrimination in Employment Act) OR 42 U.S.C. § 12112, et seq., (Americans with Disabilities Act)

, (Name of Plaintiff)

vs.

CASE NO: (To be assigned by Clerk)

, . (Name of Defendant which should generally be the name of the Employer.)

ANSWER ALL QUESTIONS ON THE FOLLOWING PAGES:

I.

PARTIES: A. PLAINTIFF:

State your full name, full mailing address, and phone number: Name of Plaintiff: Mailing address:

Phone #

(

)

B.

DEFENDANT(S):

State the name of the Defendant in the first line (place where you were employed or sought employment) and mailing address.

Defendant's name: Mailing address:

PLEASE CONTINUE ANSWERING ALL QUESTIONS ON THE FOLLOWING PAGES

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II.
1. 2.

FACTUAL BACKGROUND:
Defendant Employer is: Defendant's business is: Business address - location of headquarters: Plaintiff G sought employment from Defendant on or G was employed by Defendant from until .

3.

4.

The location where Plaintiff was employed or sought employment was: (street address) (city/county and state)

5.

Plaintiff filed charges against Defendant with the Equal Employment Opportunity Commission on: .

6.

The Respondent(s) named on the EEOC charging document: . (attach document).

7.

Defendant discriminated against Plaintiff as described in Section III of this complaint on or about (day) G gender/sex G color G national origin G age Date of Birth is (month), and (year).

8.

As claimed in the EEOC charging document, Defendant discriminated against Plaintiff because of Plaintiff's: G race G religion G disability G other (explain): (please identify)

9.

Defendant discriminated against Plaintiff when Defendant: G failed to hire Plaintiff G failed to promote Plaintiff G other (explain): G terminated Plaintiff's employment G retaliated against Plaintiff G unequal treatment

G failed to accommodate Plaintiff's disability

10.

The EEOC issued a Notice of Right to Sue which was dated: which was received by Plaintiff on » » The notice is attached to this complaint. . G yes G no « «

and

11.

Plaintiff also filed charges concerning this discrimination with the Florida Commission on Human Relations on: or G did not file.

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JURISDICTIONAL AND STATUTORY BASIS OF CLAIM:
This action is brought for discrimination in employment pursuant to: G G G Title VII of the Civil Rights Act of 1964, as codified, 42 U.S.C. §§ 2000e to 2000e-17 (race, color, gender, religion, national origin) Age Discrimination in Employment Act of 1967, as codified, 29 U.S.C. §§ 621634 Americans with Disabilities Act of 1990, as codified, 42 U.S.C. §§ 12112-12117

Note: To bring suit in federal court under any of the above Acts, you must first obtain a right to sue letter from the Equal Employment Opportunity Commission. Jurisdiction is specifically conferred upon this United States District Court by the aforementioned statutes, as well as 28 U.S.C. §§ 1331, 1343.

III.

STATEMENT OF FACTS:

Briefly state the FACTS of this case. Describe how each Defendant was involved and what each person did or did no t do which gives rise to your claim. In des cribing wha t happen ed, state the names of persons involved, dates, and plac es. Do not make any legal argum ents or cite to any cases or statutes. You must set forth sep arate factual allega tions in sep arate ly num bere d pa ragraph s. Additional page s m ay be a dde d to state the relevant facts if necessary. Absent extraordinary circumstances, no more than two (2) additional pages sho uld be attached .

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12.

The facts as set forth above in Section III of this complaint: G are still being committed by Defendant against Plaintiff G are no longer being committed by Defendant against Plaintiff Plaintiff: G still works for Defendant G no longer works for Defendant, or not hired.

13.

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14.

If this is a disability-related claim, did Defendant deny a request for a reasonable accommodation? G yes G no Explain:

IV.

REQUEST FOR RELIEF:

As relief from the allegations of discrimination as stated above, Plaintiff prays that the Court grant the following relief to Plaintiff: G Defendant be directed to employ Plaintiff G Defendant be directed to re-employ Plaintiff G Defendant be directed to promote Plaintiff G Defendant be directed to As additional relief to make Plaintiff whole, Plaintiff seeks:

G injunctive relief (please explain): G monetary damages (please explain): G costs and fees involved in litigating this case. and such other relief as may be appropriate, including attorney's fees, if applicable. Plaintiff seeks a G jury trial G bench trial (without jury)

I, hereby, declare under penalty of perjury that the foregoing statements have been written by me and are true and correct.

(Date)

(Signature of Plaintiff)

(please prin t or type nam e legibly)

(full mailing address)
Revised 08/2005

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