Free [PFP#900560490] - Louisiana

Rev. 04/02/09

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA
INSTRUCTIONS FOR FILING A LAWSUIT UNDER THE CIVIL RIGHTS ACT OF 1964 (EEOC 42:2000)

This is in response to your inquiry abut a lawsuit you may wish to bring under Title VII of the Civil Rights Act of 1964. Under this law the Court is, upon application by a complainant, permitted to appoint an attorney for the applicant and to allow commencement of the action without prepayment of fees, costs or security. Any such application is, at the direction of this Court, to be in writing and to be filed with this office. Attached for your convenience are forms that can be used for: (1) (2) your complaint; your motion to allow commencement of the action without prepayment of the $350.00 filing fee if you prefer not to pay the fee at this time; your motion for appointment of counsel if you desire to have counsel appointed to assist you.

(3)

You are cautioned that any lawsuit under Title VII to be brought by you or on your behalf must be filed within 90 days after receipt by you of the EEOC's "right-to-sue" notice. A delay on your part in filing an application for appointment of an attorney or waiver of prepayment of fees may result in loss of rights under Title VII. The clerk will automatically refer any motions you submit in connection with your complaint to the appropriate Judge or Magistrate Judge, and will promptly send you copies of any orders signed in response to your motions. If your case is allowed to be filed the order will reflect a Civil Action number which you should provide with all future inquiries and pleadings. If you need additional copies of this application form or further information, please advise this office. Very truly yours, TONY R. MOORE Clerk of Court 300 Fannin Street, Suite 1167 Shreveport, LA 71101-1167 318-676-4273

Rev. 9/91

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA

____________________________ Plaintiff versus ___________________________ Defendant Civil Action No.____________________ / Judge Mag.Judge

COMPLAINT UNDER SECTION 706(f) OF CIVIL RIGHTS ACT OF 1964

Describe in your own words the employment practices about which you A. are complaining, identifying the persons, firms, companies, unions, agencies or bodies you say have engaged in such practices. Attach an additional sheet, if necessary. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Have you filed with the Equal Employment Opportunity Commission B. (EEOC) a Charge relating to such practices? _____ Yes _____ No Have you received from the EEOC a letter notifying you of your C. "right-to-sue" respecting such charges? _____ Yes _____ No If "yes", attach a copy of such letter and notice, and state when you received same. Date received:__________________________

Have you received from the EEOC a copy of its Determination with D. regard to your charges? _____ Yes _____ No If "yes" attach a copy of such determination. Also, if you disagree with any of the EEOC's findings or conclusions, state why: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ E. Give any other information you desire to disclose which supports your claim of discriminatory employment practices. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Under penalty of perjury, I declare that the information given in F. this complaint is true and correct. Date:______________________ ______________________________ Signature ______________________________ Street Address or P. O. Box ______________________________ City, State, Zip Code / Area Code / Telephone Number WITNESSES: ____________________________ ____________________________

Rev. 7/93

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA

Plaintiff versus Civil Action No. / Defendant Judge Mag.Judge

APPLICATION TO PROCEED IN FORMA PAUPERIS UNDER SECTION 706(f) OF CIVIL RIGHTS ACT OF 1964 1. 2. FULL NAME ADDRESS (Street Address or P. O. Box)

(City) 3. MARITAL STATUS: Single Divorced

(State) Married

(Zip Code)

Separated Widowed

4.

Are you presently employed? Yes No If the answer is "yes," give your occupation, the name and address of your employer and the gross and net amount of your salary.

(Occupation)

(Gross Salary)

(Net Salary)

(Name and address of Your employer) 5. If you are not presently employed, state the date of your last employment, the name and address of your employer and your salary.

(Date last employed)

(Salary)

(Name and Address of last Employer) 1

6.

If you are married and if your spouse is employed, state his/her name, occupation, employer, address of employer and salary.

(Name of spouse) 7.

(Occupation)

(Salary)

Approximately how much money have you received in the past twelve months from the following sources: as wages, salary, commissions or earned income of any kind?

as workman's compensation or disability insurance?

as rent payments, interest, dividends? as pensions, annuities or life insurance payments?

from social security, unemployment compensation or welfare payments?

as gifts or inheritance? from other sources? 8. How much money do you own or have in any checking or savings account?

9.

Do you own or have any interest in any real estate, automobiles or other vehicles, boats, stocks, bonds, notes, or any other valuable property (excluding ordinary household furnishings and clothing)? Yes _____ No _____ If "yes", give a description of the property and its estimated value.

10.

Is anyone dependent on you for support? Yes _____ No _____ If "yes", give names, ages, relationship to you, and the amount you contribute toward their support.

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11.

List any debts you have and the amount owed. Creditor Amount Owed

12.

List your monthly living expenses.

I certify under penalty of perjury that the above information is true and correct to the best of my knowledge. ___________________________________ (Signature of Applicant)

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Rev. 7/93

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA

Plaintiff versus Civil Action No. / Defendant Judge Mag.Judge

MOTION FOR APPOINTMENT OF COUNSEL UNDER SECTION 706(f) OF CIVIL RIGHTS ACT OF 1964 PART 1: EFFORTS TO OBTAIN COUNSEL

Declaring that the information I have given below is true and correct, I apply to the court for appointment of an attorney. A. Have you talked with any attorney about handling your claim? Yes No

If "yes", give the following information abut each attorney with whom you talked: Attorney When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim?

Attorney When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim?

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Attorney When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim?

Explain any other efforts you have made to contact an attorney to B. handle your claim:

C. Give any other information which supports your application for the court to appoint counsel:

D. Name and address of each attorney who has represented you in the last ten (10) years:

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PART 2:

FINANCIAL INFORMATION

(DO NOT FILL THIS OUT IF YOU HAVE ALREADY SUPPLIED THIS INFORMATION IN THE APPLICATION TO PROCEED WITHOUT PREPAYING COSTS). 1. 2. FULL NAME ADDRESS (Street Address or P. O. Box)

(City)

(State)

(Zip Code)

(Telephone)

3.

MARITAL STATUS:

Single Divorced

Married

Separated Widowed

4.

Are you presently employed? Yes No If the answer is "yes," give your occupation, the name and address of your employer and the gross and net amount of your salary.

(Occupation)

(Gross Salary)

(Net Salary)

(Name and address of Your employer)

5.

If you are not presently employed, state the date of your last employment, the name and address of your employer and your salary.

(Date last employed)

(Salary)

(Name and Address of last Employer)

6.

If you are married and if your spouse is employed, state his/her name, occupation, employer, address of employer and salary.

(Name of spouse)

(Occupation)

(Salary)

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7.

Approximately how much money have you received in the past twelve months from the following sources: as wages, salary, commissions or earned income of any kind?

as workman's compensation or disability insurance?

as rent payments, interest, dividends? as pensions, annuities or life insurance payments?

from social security, unemployment compensation or welfare payments?

as gifts or inheritance? from other sources? 8. How much money do you own or have in any checking or savings account? $

9.

Do you own or have any interest in any real estate, automobiles or other vehicles, boats, stocks, bonds, notes, or any other valuable property (excluding ordinary household furnishings and clothing)? Yes _____ No _____ If "yes", give a description of the property and its estimated value.

10.

Is anyone dependent on you for support? Yes _____ No _____ If "yes", give names, ages, relationship to you, and the amount you contribute toward their support.

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11.

List any debts you have and the amount owed. Creditor Amount Owed

12.

List your monthly living expenses.

Under penalty of perjury, I declare that the information given in this complaint is true and correct. Date:______________________ ______________________________ Signature ______________________________ Street Address or P. O. Box ______________________________ City, State, Zip Code __________/___________________ Area Code / Telephone Number

WITNESSES: ____________________________ ____________________________

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