THE FEE FOR A COMPLAINT IS $400.00 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 $400.00 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 14 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.4/23/13 American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK ___________________________________ ___________________________________ ___________________________________ NAME OF PLAINTIFF(S) v. ___________________________________ ___________________________________ ___________________________________ NAME OF DEFENDANT(S) 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. COMPLAINT _________ 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. -1American LegalNet, Inc. www.FormsWorkFlow.com Jurisdiction is specifically conferred upon this United States District Court by the aforementioned 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 -2- American LegalNet, Inc. www.FormsWorkFlow.com 4. The discriminatory conduct of which I complain in this action includes (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 _____________________________________________________ disability __________________________________________________________ age. If age is checked, answer the following: I was born in ________. At the time(s) defendant(s) discriminated against me, Year I was [ ] more [ ] less than 40 years old. (check one). -3American LegalNet, Inc. www.FormsWorkFlow.com NOTE: Only those grounds raised in the charge filed with the Equal Employment Opportunity Commission can be considered by the federal district court. 8. The facts of my case are as follows: (Att