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Employee Discrimination Complaint Package Form. This is a California form and can be use in USDC Northern Federal.
Tags: Employee Discrimination Complaint Package, California Federal, USDC Northern
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA
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HOW TO FILE AN EMPLOYMENT DISCRIMINATION COMPLAINT:
INSTRUCTIONS FOR PERSONS WITHOUT AN ATTORNEY
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This packet includes each of the following forms:
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1.
How to File an Employment Discrimination Complaint (Intake 1);
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2.
Employment Discrimination Complaint (Intake 2);
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3.
Application to Proceed In Forma Pauperis (Intake 3);
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I.
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A.
Three completed copies of each applicable form should be sent to the Court.
Upon filing, the Clerk will return to you a file stamped copy of each document. If the documents
submitted by you are not complete, you will be advised. When you mail in the forms, you should
keep one set for your records.
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GENERAL INSTRUCTIONS
B.
All blanks must be filled in. If an entry does not apply to you, write "not
applicable" in the provided space.
C.
Effective February 7, 2005, the filing fee for a complaint is $250.00. If you are
financially unable to pay that fee, you must complete the Application to Proceed In Forma
Pauperis (Intake 3). If you are able to pay the $250.00 filing fee, you need not complete the
Application to Proceed In Forma Pauperis. However, you must prepare a summons, have it
issued by the Clerk's Office and make arrangements with a private process server to have your
summons and complaint served upon the defendant.
D.
Your complaint must be filed within the time specified by your Notice-Of-RightTo-Sue letter.
E.
If you contact the Court about your case, you must use the name and number of
the case: for instance. Jones v. Acme Construction, C02-0123ABC. This number will be
stamped on the copies of your documents returned by the Clerk when your case is filed. The
letters at the end of the number are the initials of the judge to whom your case has been randomly
assigned. These letters are part of the case number and must be used by you if you inquire about
your case.
F.
You must notify the Clerk promptly if your mailing address changes. If the Court
is unable to contact you, your case may be dismissed for lack of prosecution.
G.
Before mailing your forms to the Court, you should remove these instructions and
keep for reference.
H.
If you are filing a complaint against a Federal Agency, you should fill out all parts
of the forms that apply to you and add any additional information that is appropriate.
I.
If you are a minor, include only your initials on all documents where your name is
requested. DO NOT INCLUDE YOUR NAME.
II.
EMPLOYMENT DISCRIMINATION COMPLAINT (Intake 2)
A.
Insert the name of the employer(s) against whom you are complaining in the
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heading above the word "Defendant(s)." If you are complaining against a federal agency,
department or unit, insert the title of the head of that agency, department or unit above the word
"Defendant(s)." (For example, if you are complaining against the U.S. Postal Service, insert
"Postmaster General;" if you are complaining against the U.S. Navy, insert "Secretary of the
Navy.") Write your name above the word "Plaintiff."
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B.
Paragraphs 1 and 2 - Be sure to provide full and accurate addresses.
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C.
Paragraph 9 - Be sure to attach a copy of your Notice-Of-Right-To-Sue letter.
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THE COMPLAINT MUST BE FILED WITHIN THE TIME SPECIFIED
IN YOUR NOTICE-OF-RIGHT-TO-SUE LETTER
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III.
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A.
This form should be used ONLY if you are financially unable to pay the $250.00
filing fee. Each complaint must be accompanied with either a $250.00 payment or a completed
Application to Proceed In Forma Pauperis.
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APPLICATION TO PROCEED IN FORMA PAUPERIS (Intake 3)
B.
All blanks must be filled in. If an entry does not apply to you, write "not
applicable" in the provided space.
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When the forms are completed, bring them or mail them to:
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Clerk, United States District Court
450 Golden Gate Avenue
P.O. Box 36060
San Francisco, CA 94102
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Form-Intake 1 (Rev. 2/05)
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UNITED STATES DISTRICT COURT
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NORTHERN DISTRICT OF CALIFORNIA
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)
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Plaintiff,
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Defendant(s). )
)
)
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vs.
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1.
CASE NO.
EMPLOYMENT DISCRIMINATION
COMPLAINT
Plaintiff resides at:
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Address
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City, State & Zip Code
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Phone
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2.
Defendant is located at:
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Address
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City, State & Zip Code
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3.
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ment discrimination. Jurisdiction is conferred on this Court by 42 U.S.C. Section 2000e-5.
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Equitable and other relief is sought under 42 U.S.C. Section 2000e-5(g).
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4.
This action is brought pursuant to Title VII of the Civil Rights Act of 1964 for employ-
The acts complained of in this suit concern:
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a.
Failure to employ me.
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b.
Termination of my employment.
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c.
Failure to promote me.
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d.
Other acts as specified below.
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5.
Defendant's conduct is discriminatory with respect to the following:
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a.
My race or color.
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b.
My religion.
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c.
My sex.
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d.
My national origin.
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e.
Other as specified below.
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6.
The basic facts surrounding my claim of discrimination are:
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The alleged discrimination occurred on or about
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(DATE)
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8.
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California Department of Fair Employment and Housing) regarding defendant's alleged
I filed charges with the Federal Equal Employment Opportunity Commission (or the
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discriminatory conduct on or about
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(DATE)
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The Equal Employment Opportunity Commission issued a Notice-of-Right-to-Sue letter
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(copy attached), which was received by me on or about
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(DATE)
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Plaintiff hereby demands a jury for all claims for which a jury is permitted:
Yes
No
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11.
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including injunctive orders, damages, costs, and attorney fees.
WHEREFORE, plaintiff prays that the Court grant such relief as may be appropriate,
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DATED:
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SIGNATURE OF PLAINTIFF
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(PLEASE NOTE: NOTARIZATION
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IS NOT REQUIRED.)
PLAINTIFF'S NAME
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(Printed or Typed)
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UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA
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Plaintiff,
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vs.
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Defendant.
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) CASE NO.
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) APPLICATION TO PROCEED
) IN FORMA PAUPERIS
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I,
, declare, under penalty of perjury that I am the plaintiff
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in the above entitled case and that the information I offer throughout this application is true and
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correct. I offer this application in support of my request to proceed without being required to
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prepay the full amount of fees, costs or give security. I state that because of my poverty I am
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unable to pay the costs of this action or give security, and that I believe that I am entitled to relief.
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In support of this application, I provide the following information:
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1.
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If your answer is "yes," state both your gross and net salary or wages per month, and give the
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name and address of your employer:
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Gross:
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Employer:
Are you presently employed?
Yes
No
Net:
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If the answer is "no," state the date of last employment and the amount of the gross and net salary
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and wages per month which you received.
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2.
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following sources:
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Have you received, within the past twelve (12) months, any money from any of the
a.
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Business, Profession or
Yes
No
Yes
No
self employment?
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b.
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Income from stocks, bonds,
or royalties?
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c.
Rent payments?
Yes
No
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d.
Pensions, annuities, or
Yes
No
Yes
No
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life insurance payments?
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e.
Federal or State welfare payments,
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Social Security or other govern-
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ment source?
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If the answer is "yes" to any of the above, describe each source of money and state the amount
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received from each.
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3.
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Spouse's Full Name:
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Spouse's Place of Employment:
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Spouse's Monthly Salary, Wages or Income:
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Gross $
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4.
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Are you married?
Yes
No
Net $
a.
List amount you contribute to your spouse's support:$
b.
List the persons other than your spouse who are dependent upon you for support
and indicate how much you contribute toward their support. (NOTE: For minor
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children, list only their initials and ages. DO NOT INCLUDE THEIR NAMES.)
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5.
Do you own or are you buying a home?
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Estimated Market Value: $
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6.
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Make
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Is it financed? Yes
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Yes
No
Monthly Payment: $
Amount of Mortgage: $
Do you own an automobile?
Yes
Year
No
No
Model
If so, Total due: $
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7.
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Name(s) and address(es) of bank:
Do you have a bank account? Yes
No
(Do not include account numbers.)
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Present balance(s): $
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Do you own any cash? Yes
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Do you have any other assets? (If "yes," provide a description of each asset and its estimated
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market value.)
No
Amount: $
Yes
No
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8.
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Rent: $
Utilities:
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Food: $
Clothing:
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Charge Accounts:
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Name of Account
What are your monthly expenses?
Monthly Payment
Total Owed on This Account
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$
$
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$
$
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$
$
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9.
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they are payable. Do not include account numbers.)
Do you have any other debts? (List current obligations, indicating amounts and to whom
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10.
Does the complaint which you are seeking to file raise claims that have been presented in
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other lawsuits?
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Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in
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which they were filed.
Yes
No
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I declare under the penalty of perjury that the foregoing is true and correct and understand that a
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false statement herein may result in the dismissal of my claims.
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DATE
SIGNATURE OF APPLICANT
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