Free [PFP#602373254] - Maryland

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND

(Full name and address of the plaintiff) v. Civil Action No. (Leave blank. To be filled in by Court.)

(Full name and address of the defendant(s)) COMPLAINT FOR EMPLOYMENT DISCRIMINATION 1. 2. Plaintiff is a resident of ________________________________________________. (Fill in county or city and state of residence) Defendant(s) reside(s) or does business at the following location: _______________

_____________________________________________________________________________. 3. This action is brought pursuant to (check all spaces 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, sex, or national origin. Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. §§ 621, et seq., for employment discrimination on the basis of age. My date of birth is: ________________________________________________. Rev. 6/2000

Rehabilitation Act of 1973, as amended, 29 U.S.C. §§ 701, et seq., for employment discrimination on the basis of a disability by an employer which constitutes a program or activity receiving federal financial assistance. Americans with Disabilities Act of 1990, as amended, 42 U.S.C. §§ 12101, et seq., for employment discrimination on the basis of disability. 4. I am complaining about (check all that apply): Failure to hire me. I was refused a job on the following date: ________________ _________________________________________________________________. Termination of my employment. I was terminated from my employment on the following date: ____________________________________________________. Failure to promote me. I was refused a promotion on the following date: _________________________________________________________________. Other (explain what happened): _______________________________________ _________________________________________________________________ _________________________________________________________________. 5. apply): race 6. color religion sex age national origin disability The conduct of Defendant(s) was discriminatory because it was based on (check all that

The facts of my claim are: ______________________________________________

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Rev. 6/2000 2

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. 7. 8. The approximate number of people employed by Defendant is: ________________. The events I am complaining about took place on the following dates or time period:

_____________________________________________________________________________. 9. I filed charges on the following date: ____________________________, with: Equal Employment Opportunity Commission (EEOC) Maryland Human Relations Commission Other (give name of agency and location): _______________________________ _________________________________________________________________. 10. I received a right to sue letter (attach copy) on the following date: ______________ _________________________________________________________________. WHEREFORE, Plaintiff asks the Court to grant such relief as may be appropriate, including but not limited to (check all that apply): Injunctive relief (specify what you want the Court to order): _________________ __________________________________________________________________ Rev. 6/2000 3

_________________________________________________________________. Back pay. Reinstatement to my former position. Monetary damages in the amount of: ___________________________________. Costs and attorneys fees. Other (specify): ____________________________________________________ _________________________________________________________________.

______________________________ (Date)

____________________________________ (Signature) ____________________________________ ____________________________________ ____________________________________ ____________________________________ (Printed name, address and phone number of Plaintiff)

Rev. 6/2000

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