UNITED STATES DISTRICT COURT FOR THE NORTHERN DIST RICT OF I LLINOIS EASTERN DIV ISION ___________________________________) ) ___________________________________) ) ___________________________________) CIVIL ACTION (Name of the plaintiff or plaintiffs) ) ) v. ) NO.___________________ ) ___________________________________) ) ___________________________________) ) ___________________________________) (Name of the defendant or defendants) ) COMPLA INT OF EMPLOYMEN T DISCRIMI NATION 1. This is an action for employment discrimination. 2. The plaintiff is _______________________________________________________ __ of the county of ________________________________in the state of_______________ ______. 3. The defendant is _______________________________________________________, whose street address is ______________________________________________________ _____, (city)______________(county)______________(state)______________(ZIP)________ (Defendants telephone number)(____) ________________________ 4. The plaintiff sought employment or was employed by the defendant at (street address) ______________________________________________ (city)_________________ ___ (county)___________ (state)__________ (ZIP code)__________ American LegalNet, Inc. www.USCourtForms.com>>>> 25. The plaintiff [check one box] was denied employment by the defendant. (a) G (b) G was hired and is still employed by the defendant. (c) was employed but is no longer employed by the defendant. G 6. The defendant discriminated against the plaintiff on or about, or beginning on or about, (month)_____________, (day)________, (year)_________. 7.1 (Choose paragraph 7.1 or 7.2, do not complete both.) (a) The defendant is not a federal governmental agency, and the plaintiff [check filed a charge or charges against the defendant one box] G has not G has asserting the acts of discrimination indicated in this complaint with an y of the following government agencies: (i) G the United States Equal Employment Opportunity Commission, on or about (month)_____________ (day)________ (year)_________. (ii) G the Illinois Department of Human Rights, on or about (month)_____________ (day)________ (year)_________. (b) If charges were filed with an agency indicated above, a copy of the charge is attached. G YES. G NO, but plaintiff will file a copy of the charge within 14 days. It is the policy of both the Equal Employment Opportunity Commission and the Illinois Department of Human Rights to cross-file with the other agency all charges received. The plaintiff has no reason to believe that this policy was not followed in this case. 7.2 The defendant is a federal governmental agency, and (a) the plaintiff previously filed a Complaint of Employment Discrimination with the defendant asserting the acts of discrimination indicated in this court complaint. 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3 G Yes (month)________________ (day)_______ (year) _________ G No, did not file Complaint of Employment Discrimination (b) The plaintiff received a Final Agency Decision on (month)____________ (day) _________ (year) __________. (c) Attached is a copy of the (i) Complaint of Employment Discrimination, G YES G NO, but a copy will be filed within 14 days. (ii) Final Agency Decision G YES G NO, but a copy will be filed within 14 days. 8. (Complete paragraph 8 only if defendant is not a federal governmental a gency.) . (a) the United States Equal Employment Opportunity Commission has not issued G a Notice of Right to Sue. (b) the United States Equal Employment Opportunity Commission has issued a G Notice of Right to Sue, which was received by the plaintiff on (month)_____________ (day)________ (year)_________ a copy of which Notice is attached to this complaint. 9. The defendant discriminated against the plaintiff because of the plaintiffs [check only those that apply]: (a) Age (Age Discrimination Employment Act). G (b) G Color (Title VII of the Civil Rights Act of 1964 and 42 U.S.C. 1981). 3 American LegalNet, Inc. www.USCourtForms.com>>>> 4 (c)G Disability (Americans with Disabilities Act or Rehabilitation Act) (d)G National Origin (Title VII of the Civil Rights Act of 1964 and 42 U.S.C. 1981). (e) Race (Title VII of the Civil Rights Act of 1964 and 42 U.S.C. 1981). G (f) Religion (Title VII of the Civil Rights Act of 1964) G (g)G Sex (Title VII of the Civil Rights Act of 1964) 10. If the defendant is a state, county, municipal (city, town or village) or other local governmental agency, plaintiff further alleges discrimination on the basis of race, color, or national origin (42 U.S.C. 1983). 11. Jurisdiction over the statutory violation alleged is conferred as follows: for Title VII claims by 28 U.S.C.1331, 28 U.S.C.1343(a)(3), and 42 U.S.C.2000e-5(f)(3); for 42 U.S.C.1981 and 1983 by 42 U.S.C.1988; for the A.D.E.A. by 42 U.S.C.12117; for the Rehabilitation Act, 29 U.S.C. 791. 12. The defendant [check only those that apply] (a)G failed to hire the plaintiff. (b) terminated the plaintiffs employment. G failed to promote the plaintiff. (c) G (d)G failed to reasonably accommodate the plaintiffs religion. (e)G failed to reasonably accommodate the plaintiffs disabilities. (f) failed to stop harassment; G (g)G retaliated against the plaintiff because the plaintiff did something to assert rights protected by the laws identified in paragraphs 9 and 10 above; (h)G other (specify):______________________________________________ ___________________________________________________________________ 4 American LegalNet, Inc. www.USCourtForms.com>>>> 5 ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 13. The facts supporting the plaintiffs claim of discrimination are as follows: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 14. [ AGE DISCRIMINATION ONLY] Defendant knowingly, intentionally, an