Free EEO Complaint Form - Race, Color, Sex, Religion, National Origin - Michigan


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Pages: 7
Date: April 19, 2005
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State: Michigan
Category: Court Forms - Federal
Word Count: 1,808 Words, 9,043 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.miwd.uscourts.gov/FORMS/eeocvii.pdf

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UN ITED ST A TES D IST RICT COU RT W ESTERN DIST RICT OF MICH IGAN _______________

Name of Plaintif f(s) vs. Civil No. ____________________ (To be supplied by the Clerk of t he Court )

Name of Defend ant( s)

INSTRUCTIONS FOR FILLING OUT THIS FORM: If you w ish to file a lawsuit for t he violation of your civil righ t s yo u are t he plaintiff . The person, employer, company, union, or employment agency you sue is t he defendant. If th ere is m ore t han on e plain t if f or def endant , eac h mu st be iden t if ied by name and add ress. Each plain t if f must also st at e th e fac t s of th e disc rim inat ory act unles s t he f act s are t he same fo r all plain ti ff s. To beg in a lawsuit you must fi le a complaint w ith t he court. This form is t o help you file a complaint under Ti tl e VII of th e Civil Right s Act of 19 64 , t he Equal Pay A ct of 19 63 , or b ot h. Th is f orm w ill assist you in following the Federal Rules of Civil Procedure for filing the complaint in United States District Court. Title VII prohibits discrimination on the basis of race, color, sex, religion, or national origin. To file suit under Title VII fill out t he part of t his complaint marked COUNT I - TITLE VII. For Title VII suits you should attach a copy of t he EEOC "Right to Sue" let ter. If y our Tit le VII c laim is b ased on t he fac t t hat d if feren t w ages are paid t o emplo yees doin g simil ar jobs and the diff erence betw een the employees is their sex, then you may have an additional claim under the Equal Pay Act of 196 3. To file a complaint under the Equal Pay Act, fill out the part of t he form marked COUNT II - EQUAL PAY ACT. If a claim violates the Equal Pay Act it will also violate Title VII. A Title VII violation, how ever, does not necessarily violate the Equal Pay Act. The Equal Pay Act prohibits only pay diff erences because of sex. You m ay no t be able t o f ill in ev ery b lank . If you are unab le t o pro vid e th e request ed inf orm ation, st ate either "unknown" or "not applicable" or some other similar explanation. If you need help ask the Clerk at the filing desk. Please print legibly.

COMPLAINT PARTIES 1. Plaintif f' s address is:

street cit y zip c ode ( ) phone num ber county stat e

2.

Defend ant' s address is:

str eet cit y zip c ode ( ) phone num ber county stat e

COUNT I - TITLE VII

NA TURE OF PROCEEDINGS 3. Plaintif f seeks legal and equitable relief for the denial of certain rights secured by the Civil Rights A ct of 19 64 , co dif ied as 42 USC Sectio ns 20 00 e to 2 00 0e-1 7. Such relief is authorized by 4 2 USC Section 2 00 0e-5(g). JURISDICTION 4. This Court h as jurisdict ion pursuant to 4 2 USC Section 2 00 0e-5(f )(1)(3). ADDRESS 5. Is the address where the discriminatory act(s) took place the same address as for defendant? _____ yes _____ no. If different from the defendant' s address, the discriminatory act(s) took plac e at:

str eet cit y zip c ode ( ) phone num ber county stat e

FACTS

If you w ere not hired because of you r race, c olor, sex, relig ion, or nat ional ori gin, pl ease com plet e the follow ing.

Refusal to Hire
6. A. B. C. Provide a brief statement of the fact s to include the follow ing: Date of application If not hired, the date of refusal to hire If you w ere not hired because of you r sex, race, col or, relig ion, or nat ional ori gin, pl ease list the names (if Known) of other applicants who were hired and their sex, race, religion, or nation al origin (w hichever is applicable t o your case):

If you w ere treated diff erently than other employees because of your race, color, sex, religion or national origin, please complete the following:

Diff erence in Terms and Conditions of Employment Because of Race, Color, Sex, Religion, or National Origin
7. A. Provide a brief statement of the fact s to include the follow ing: Job position plaintiff held at time of discharge, demotion, denial of promotion or job bid, denial or difference in pay or benefits, or other discriminatory act:

B. C.

Date the act(s) occurred: Was there a general layoff or reduct ion in f orce (if y ou know )? ______ yes ______ no Rate of pay w hen this occurred $ per ho ur/ per w eek (please c irc le)

D. E.

Name of any individual who was treated differently than you because of your race, color, sex, religion, or national ori gin (if know n):

F.

The individual's race, color, sex, religion, or national origin (if know n) who w as treated diff erently from you:

G.

Sexual harassment consist ed of th e fol low ing act s, by th e fol low ing nam ed indiv iduals:

Fact ual Statement
The f ollow ing is p laint if f' s accoun t o f t he fac ts:

CAUSE OF ACTION 8. Defendant violat ed plaintif f' s civil righ ts by the f ollow ing discrimi natory act(s): A._____Failure to hire plaintiff ; B._____Termination of plaint iff ' s employment; C._____Demotion of plaintiff ; D._____Denial of promotion or job bid t o plaintiff ; E._____Sexual Harassment; F._____Denial of t he same terms and conditions of employment given to ot her employees but denied plaintiff because of race, color, sex, religion or national origin; G._____Other Act s (please specify )

9.

Defendant, in commit ting t he above acts, has violated Title VII of t he Civil Rights Act s of 19 64 because of plaint iff ' s (check t he correct lett er(s)): A._____rac e B._____color C._____sex (includes harassment and pregnancy/maternity) D._____religion E._____national origin

10.

Charges were filed w ith t he Equal Employment Opportunit y Commission on (state t he date or best estimate):

Att ach a copy of the Charge you filed wit h the Equal Employment Opportunit y Commission.

11.

Charges w ere fil ed w it h t he Mic higan Depart ment of Civil Rights o n (st ate t he dat e or best estimate): .

At tac h a copy of th e Charge you f iled w it h t he Mic higan Depart ment of Civil Rights.

STATUTORY PREREQUISITE 12. Plaintif f received a "Right to Sue" let ter from t he Equal Employment Opportunit y Commission on (i nsert dat e) n th e 90 -day period as required by 42 USC Sect ion 20 00 e-5.

Att ach a copy of " Right to Sue" lett er.

REQUEST FOR APPOINTMENT OF ATTORNEY

If you have been unable to get an attorney t o take your case and you w ant the court to appoint counsel for you, please complete the follow ing:

13.

Plaintif f has done the follow ing things in an effort to obt ain counsel:

14.

Plaintiff has been unable to retain counsel and requests the court to appoint an attorney. _____ yes _____ no. RELIEF

Check applicable lett er(s).

15.

Plaintif f requests the follow ing: A._____That all fees, costs or security be waived; B._____That the Court grant such relief as may be appropriate, including injunctive orders, damages, c ost s and att orney' s fees; C._____That th e Court grant reinstatement w here app ropr iat e.

COUNT II - EQUAL PAY ACT NA TURE OF PROCEEDINGS 16. Plaintiff seeks relief for the denial of certain rights secured by the Equal Pay Act of 1963, codif ied as 29 USC Section 2 06 (d). Such relief i s authorized under 29 USC Sect ion 62 6(b). JURISDICTION 17. This Court h as jurisdict ion pursuant to 2 9 USC Section 2 16 (b). ADDRESS 18. Is t he addres s w here the di scr iminatory act (s) t ook plac e t he sam e address as f or d ef endant ? _____ yes _____ no. If different from the defendant' s address, the discriminatory act(s) took plac e at: street cit y ( zip c ode ) phone num ber FACTS 19. A. Provide a brief statement of the fact s to include the follow ing: Job position plain tif f held at th e ti me w hen t he pay disc rim inat ion occ urred count y stat e

B. C.

Rate of pay at t ime this occurred $

per hou r/p er w eek (please c irc le)

Names and job p osit ions held by i ndivid uals w ho w ere paid more th an plai nt if f because of th at indivi dual' s sex

The f ollow ing is p laint if f' s accoun t o f t he fac ts:

CAUSE OF ACTION 20. By committing the above acts defendant has violated the E qual Pay Act of 1963 by using sex as a determining factor for pay. Defendant' s conduct w as willf ul.

21.

22.

Plaint if f fi led c harges w it h t he Equal Employm ent Oppor tunity Com mission on (st ate th e dat e or best estimate) .

Att ach a copy of the Charge you filed wit h the Equal Employment Opportunit y Commission.

23.

Plaintif f f iled ch arges w it h t he Mic higan Depart ment of Civil Rights o n (st ate t he dat e or best estimate) .

At tac h a copy of th e Charge you f iled w it h t he Mic higan Depart ment of Civil Rights.

STATUTORY PREREQUISITE 24. This suit has been filed wit hin three years of the wilf ul discriminatory act. JURY TRIAL 25. Plaintif f requ ests a jury tri al for the Equal Pay Act claim. _____ Yes _____ No

RELIEF

Check appl icable let ters.

26.

Plaintif f requests the follow ing: A._____ That all fees, costs or security be waived; B._____ That the Court grant such relief as may be appropriate, including liquidated damages, cost s and att orney' s fees.

DATED:

Signature of Plaintif f