Free 44kb - New York

THE FILING FEE FOR A COMPLAINT IS $350.00 WHICH MAY BE PAID BY CASH (IF PAYING IN PERSON), MONEY ORDER, BANK CERTIFIED CHECK OR PERSONAL CHECK. IF YOU CANNOT AFFORD TO PAY THE $350.00 FILING FEE, YOU MAY ASK THE COURT TO WAIVE THE FILING FEE BY COMPLETING AND SUBMITTING A REQUEST TO PROCEED IN FORMA PAUPERIS DISCLOSING YOUR INCOME AND FINANCES. You must submit three copies of the complaint to the Pro Se Office: one must contain your original signature in ink and two may be copies of the complaint. Important: any exhibits attached to the original complaint must also be attached to the copies of the complaint. You must keep a copy of whatever you submit to the Court for yourself. In some types of actions, you are entitled to a trial by jury. However, you lose your right to a jury trial if you do not ask for it early enough. If you want a jury trial, you must write "JURY TRIAL DEMANDED" on the front page of your complaint to the right of the caption, above or below the word "complaint". You can also demand a jury trial within 10 days of service of the defendant's answer. See Rule 38(b) of the Federal Rules of Civil Procedure. NOTICE REGARDING COSTS Under Rule 54(d)(1) of the Federal Rules of Civil Procedure, Unless a federal statute, these rules, or a court order provides otherwise, costs ­ other than attorney's fees ­ should be allowed to the prevailing party. This rule provides that the prevailing party is entitled to recover costs from their adversary. These costs can range from several hundred to several thousand dollars or more. The Court will generally award costs, upon application, to the prevailing party. If you do not prevail, costs can be awarded against you even if you are pro se and were granted in forma pauperis status when you commenced the action. If you have any questions regarding this provision of the Federal Rules of Civil Procedure, please contact the Pro Se Office at 718-613-2665.
rev.1/09

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK ___________________________________ ___________________________________ ___________________________________ NAME OF PLAINTIFF(S) v. ___________________________________ ___________________________________ ___________________________________ NAME OF DEFENDANT(S) COMPLAINT

This action is brought for discrimination in employment pursuant to (check only those that apply): __________ Title VII of the Civil Rights Act of 1964, as codified, 42 U.S.C. §§ 2000e to 2000e-17 (amended in 1972, 1978 and by the Civil Rights Act of 1991, Pub. L. No. 102-166) (race, color, gender, religion, national origin). NOTE: In order to bring a suit in federal district court under Title VII, you must first obtain a right to sue letter from the Equal Employment Opportunity Commission. Age Discrimination in Employment Act of 1967, as codified, 29 U.S.C. §§ 621 - 634 (amended in 1984, 1990, and by the Age Discrimination in Employment Amendments of 1986, Pub. L. No. 92-592 , the Civil Rights Act of 1991, Pub. L. No. 102-166). NOTE: In order to bring a suit in federal district court under the Age Discrimination in Employment Act, you must first file charges with the Equal Employment Opportunity Commission.

_________

__________

Americans with Disabilities Act of 1990, as codified, 42 U.S.C. §§ 12112 - 12117 (amended by the ADA Amendments Act of 2008, Pub. L. No. 110-325 and the Civil Rights Act of 1991, Pub. L. No. 102-166). NOTE: In order to bring suit in federal district court under the Americans with Disabilities Act, you must first obtain a right to sue letter from the Equal Employment Opportunity Commission.

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Jurisdiction is specifically conferred upon this United States District Court by the aformentioned statutes, as well as 28 U.S.C. §§ 1331, 1343. Jurisdiction may also be appropriate under 42 U.S.C. §§ 1981, 1983 and 1985(3), as amended by the Civil Rights Act of 1991, Pub. L. No. 102-166, and any related claims under New York law.

1.

Plaintiff resides at:

____________________________________________________________________________ Street Address ___________________, County ____________, State ______________, ____________________. Zip Code Telephone Number

2.

Defendant(s) resides at, or its business is located at:

____________________________________________________________________________ Street Address _______________, County ____________, City _____________, State ________ Zip Code

3.

The address at which I sought employment or was employed by the defendant(s) is:

____________________________________________________________________________ Street Address _______________, County ____________, City _____________, State __________ Zip Code

4.

The discriminatory conduct of which I complain in this action includes -2-

(check only those that apply). _____ _____ _____ _____ _____ _____ _____ Failure to hire. Termination of my employment. Failure to promote. Failure to accommodate my disability. Unequal terms and conditions of my employment. Retaliation Other acts (specify): ____________________________.

NOTE: Only those grounds raised in the charge filed with the Equal Employment Opportunity Commission can be considered by the federal district court. 5. It is my best recollection that the alleged discriminatory acts occurred on: ______________________________________. Date(s) I believe that the defendant(s) (check one) _____ is still committing these acts against me. _____ is not still committing these acts against me.

6.

7.

Defendant(s) discriminated against me based on my: (check only those that apply and state the basis for discrimination, for example, what is your religion, if religious discrimination is alleged) [] [] [] [] [] race __________________ gender/sex __________ [] [] color __________________ religion _____________________

national origin _____________________________________________ My date of birth is: _______________________ Date disability _________________________________________________ age _________

NOTE: Only those grounds raised in the charge filed with the Equal Employment Opportunity Commission can be considered by the federal district court.

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8.

The facts of my case are as follows:

(Attach additional sheets as necessary)

Note:

As additional support for your claim, you may attach to this complaint a copy of the charge filed with the Equal Employment Opportunity Commission, the New York State Division of Human Rights, or the New York City Commission on Human Rights. It is my best recollection that I filed a charge with the New York State Division of Human Rights or the New York City Commission on Human Rights regarding defendant's alleged discriminatory conduct on: ______________________. Date

9.

10.

It is my best recollection that I filed a charge with the Equal Employment Opportunity Commission regarding defendant's alleged discriminatory conduct on: _____________. Date

Only litigants alleging age discrimination must answer Question #11. -4-

11.

Since filing my charge of age discrimination with the Equal Employment Opportunity Commission regarding defendant's alleged discriminatory conduct (check one), ______ ______ 60 days or more have elapsed. less than 60 days have elapsed.

12.

The Equal Employment Opportunity Commission (check one): ______ ______ has not issued a Right to Sue letter. has issued a Right to Sue letter, which I received on ______________________. Date

NOTE:

Attach a copy of the Right to Sue Letter from the Equal Employment Opportunity Commission to this complaint.

WHEREFORE, plaintiff prays that the Court grant such relief as may be appropriate, including injunctive orders, damages, costs, and attorney's fees.

________________________________ PLAINTIFF'S SIGNATURE Dated:___________________________

________________________________ Address ________________________________ ________________________________ Phone Number

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