UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF ALABAMAINSTRUCTIONS FOR FILING A COMPLAINT FORUSE IN EMPLOYMENT DISCRIMINATION CASES------------------------------------------- READ CAREFULLY------------------------------------------1.This packet consists of:1 copy of an EEOC complaint form1 copy of a summons form1 copy of an in forma pauperis motion2.Your complaint must be clearly handwritten or typewritten and signed by each plaintiff.ALL copies of the complaint must be identical in wording to the original. It is not necessaryto swear to the complaint under oath before a notary public. However, each plaintiff mustattest under penalty of perjury that the complaint is true and correct. You are warned that anyfalse statement of a material fact may subject you to prosecution and conviction.3.The Notice-of-Right-to-Sue letter issued by the EEOC must be attached to your complaint.4.All questions must be answered concisely in the proper space on the form. If you needadditional space to answer a question, you may use the reverse side of the form or use anadditional blank page. YOUR COMPLAINT SHOULD NOT CONTAIN LEGALARGUMENTS OR CITATIONS 205 YOU ARE ONLY REQUIRED TO GIVE FACTS. Youmust describe how each defendant is personally involved in the activities upon which yourclaim is based. Also, include any request for a jury trial.5. Upon receipt of the $350.00 filing fee, your complaint will be filed. If you are unable to paythe filing fee, you may petition the court to proceed in forma pauperis. If you must proceedin forma pauperis, you must complete, sign, and attest as true and correct under penalty ofperjury the petition and financial affidavit. If there is more that one plaintiff, then eachplaintiff must complete a separate petition. 6. If you pay the $350.00 filing fee, you must also fill out 2 summons forms for each defendantyou name in your complaint. Also, provide envelopes per defendant and postage for certifiedmail, return receipt requested and have the postage affixed to the envelopes. 7. It is YOUR responsibility to notify the Clerk's Office in writting of ANY change of addressyou may have during the entire time this case remains open before the court. Failure to soadvise the Clerk of your current address may result in the DISMISSAL of your case. 8.When these forms are properly completed, mail them to the clerk's office.9.Your complaint will not be considered unless it conforms to these instructions. M/D-4 American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES DISTRICT COURTFOR THE MIDDLE DISTRICT OF ALABAMA DIVISIONPLAINTIFFv.CASE ACTION NO.:JURY DEMAND (MARK ONE)G YES G NODEFENDANT EEOC COMPLAINT1.Plaintiff resides at 2.Defendant(s)' name(s)Location of principal office(s) of the named defendant(s)Nature of defendant(s)' businessApproximate number of individuals employed by defendant(s)3.This action is brought pursuant to Title VII of the Civil Rights Act of 1964 foremployement discrimination. Jurisdiction is specifically conferred on the Court by 42U.S.C. 2472000e-5. Equitable and other relief are also sought under 42 2472000e-5(g).4.The acts complained of in this suit concern:1. Failure to employ me.2. Termination of my employment.3. Failure to promote me.4. Other acts as specified below: American LegalNet, Inc. www.FormsWorkFlow.com 5.Plaintiff is:A. Presently employed by the defendant. Not presently employed by the defendant. The dates of employement were Employment was terminated because:(1) Plaintiff was discharged.(2) Plaintiff was laid off.(3) Plaintiff left job voluntarily.6.Defendant(s)' conduct is discriminatory with respect to the following:A. My race.B. My religion.C. My sex.D. My national origin.E. Other, as specified below:7.The name(s), race, sex, and the position or title of the individual(s) who allegedlydiscriminated against me during the period of my employment with the defendant companyis (are) 8.The alleged discrimination occurred on or about .9.The nature of my complaint, i.e., the manner in which the individual(s) named abovediscriminated against me in terms of the conditions of my employment, is as follows:10.The alleged illegal activity took place at American LegalNet, Inc. www.FormsWorkFlow.com 11.I filed charges with the Equal Employment Opportunity Commission regarding defendant(s)'alleged discriminatory conduct on or about .I have attached a copy of the Notice-of-Right-to-Sue letter issued by the EqualEmployment Opportunity Commission. The letter was received by me on .12.I seek the following relief:A. Recovery of back pay.B. Reinstatement to my former job, and any other relief as may be appropriate,including injunctive orders, damages, costs, and attorneys fees.Date: Signature of PlaintiffAddress & Telephone Number of Plaintiff American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES DISTRICT COURT FOR THEMIDDLE DISTRICT OF ALABAMA DIVISION))))Plaintiff(s)v.))))Defendant(s)MOTION TO PROCEED IN FORMA PAUPERIS Plaintiff(s)moves this Honorable Court for an order allowing her/him to proceed in this case without prepayment of fees, costs, or security therefor, and for grounds therefor submits the attached sworn affidavit in support of the motion.Plaintiff(s) signature American LegalNet, Inc. www.FormsWorkFlow.com District of AO 240 (Rev. 01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)UNITEDSTATESDISTRICTCOURTfor the)))))Plaintiffv.Civil Action No. DefendantAPPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS(Short Form)I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings andthat I am entitled to the relief requested.In support of this application, I answer the following questions under penalty of perjury:1.If incarcerated. I am being held at:.If employed there, or have an account in the institution, I have attached to this document a statement certified by theappropriate institutional officer showing all receipts, expenditures, and balances during the last six months for anyinstitutional account in my name. I am also submitting a similar statement from any other institution where I wasincarcerated during the last six months.2.If not incarcerated.If I am employed, my employer222s name and address are:My take-home pay or wages are: $per (specify pay period).3.Other Income. In the past 12 months, I have received income from the following sources (check all that apply):(a) Business, profession, or other self-employmentYesNo(b) Rent payments, interest, or dividendsYesNo(c) Pension, annuity, or life insurance paymentsYesNo(d) Disability, or worker222s compensation paymentsYesNo(e) Gifts, or inheritancesYesNo(f) Any other sourcesYesNoIf you answered 223Yes224 to any question above, describe below or on separate pages each source of money andstate the amount that you received and what you expect to receive in the future. American LegalNet, Inc. www.FormsWorkFlow.com AO 240 (Rev. 01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)4.Amount of money that I have in cash or in a checking or savings account: $.5.Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument orthing of value that I own, including any item of value held in someone else222s name (describe the property and its approximatevalue):6.Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and providethe amount of the monthly expense):7.Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationshipwith each person, and how much I contribute to their support:8.Any debts or financial obligations (describe the amounts owed and to whom they are payable):Declaration: I declare under penalty of perjury that the above information is true and understand that a falsestatement may result in a dismissal of my claims.Date:Applicant222s signaturePrinted name American LegalNet, Inc. www.FormsWorkFlow.com MD ALMODIFIED AO 440 (Rev. 12/09) Summons in a Civil ActionUNITEDSTATESDISTRICTCOURTfor the District of )))))Plaintiffv.Civil Action No.Defendan