Free EEO Complaint Form - Age Discrimination - Michigan

PRINT

RESET FORM

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF MICHIGAN _____________

Name of Plaintiff(s) vs.

Civil No. ______________ (To be supplied by the Clerk of the Court)

Name of Defendant(s)

INSTRUCTIONS FOR COMPLETING FORM: If you wish to file a lawsuit for violation of your civil rights because of your age, then you are the plaintiff. The person, company, or union you sue is the defendant. To begin a lawsuit you must file a complaint with the court. This form is to help you follow the Federal Rules of Civil Procedure in filing a complaint under the AGE DISCRIMINATION IN EMPLOYMENT ACT OF 1967 (ADEA). If there is more than one plaintiff or defendant, each must be identified by name and address. Each plaintiff must also state the facts of the discriminatory act unless the facts are the same for all plaintiffs. You may not be able to fill in every blank. If you are unable to provide the requested information, state either "unknown" or "not applicable" or other similar explanation. If you need help, ask the Clerk at the filing desk. Please print legibly.

COMPLAINT
PARTIES

1.

Plaintiff's address is:
street city zip code county state

( 2. Defendant's address is:
street city zip code county

)

phone number

state

(

)

phone number

NATURE OF PROCEEDINGS

3. Plaintiff seeks legal and equitable relief for the denial of certain rights secured by the Age Discrimination in Employment Act of 1967, as codified at 29 USC Sections 621634. Such relief is authorized under 29 USC Section 626 (b)(c).
JURISDICTION

4.

This Court has jurisdiction pursuant to 29 USC Section 626(c)(d).
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 place at:

street city county state

(
zip code

)

phone number

FACTS

If you were not hired because of your age, please complete.

Refusal to Hire
6. Provide a brief statement of the facts to include the following: A. B. C. Date of application If not hired, the date of refusal to hire If you were not hired because of your age, the names and ages of other applicants who were hired (if known):

2

If you were treated differently than other employees because of your age, please complete the following .

Difference in Terms and Conditions of Employment Because of Age
7. Provide a brief statement of the facts to include the following: A. Job position plaintiff held at time of discharge, demotion, or other discriminatory act

B. C.

Date the act(s) occurred Was this part of a general layoff or reduction in force (if you know)? _____ yes _____ no Rate of pay when this occurred $ circle) Replacement's name and age (if known) Name and age (if known) of any individual who was treated differently than you because of your age per hour/per week (please

D.

E. F.

Factual Statement
The following is plaintiff's account of the facts:

CAUSE OF ACTION 8. Defendant in committing the above acts has violated the Age Discrimination in Employment Act of 1967 in that defendant has discriminated against plaintiff because of plaintiff's age.

3

9.

Defendant's conduct was willful.

10. Charges were filed with the Equal Employment Opportunity Commission on (state the date or best estimate):

Attach a copy of the Charge you filed with the Equal Employment Opportunity Commission.

11. Charges were filed with the Michigan Department of Civil Rights on (state the date or best estimate):

Attach a copy of the Charge you filed with the Michigan Department of Civil Rights.

STATUTORY PREREQUISITE

12. Plaintiff has complied with 29 USC Section 626(d)(2) in that plaintiff filed a charge with the Equal Employment Opportunity Commission (check appropriate letter): A._____Within 300 days after the unlawful incident occurred; or B._____Within 30 days of notice of the end of proceedings under State law.

Note to plaintiff: the time limit for filing is A or B, whichever is earlier.

13. Plaintiff has complied with 29 USC Section 626(d) in that it has been at least 60 days since charges were filed with the Equal Employment Opportunity Commission. 14. Plaintiff was born on
day month year

and has complied with

29 USC Section 631 in that Plaintiff was at least 40 years old at the time the discriminatory act took place.

JURY TRIAL

15.

Plaintiff requests a trial by jury as provided in 29 USC Section 626(c)(2). _____ Yes _____ No

4

RELIEF

16.

Plaintiff requests the following:

Check applicable letters

A._____ That all fees, costs or security attendant to this suit be waived; B._____ That the Court grant such relief as may be appropriate, including injunctive orders, damages, costs and attorney's fees; C._____ That the Court grant reinstatement where appropriate.

DATED: Signature of Plaintiff

5