Instructions for Obtaining a Right-to-Sue Notice To file a lawsuit under the Fair Employment and Housing Act (FEHA), you must file a complaint and obtain a Right-to-Sue notice from the Department of Fair Employment and Housing (DFEH). If you choose to file a complaint using the Right-to-Sue process you should be aware that:legal referral resources. 4.DFEH will not file your complaint with the U.S. Equal Employment OpportunityCommission (EEOC). To receive a federal Right-to-Sue notice, you must contactEEOC at www.eeoc.gov or at (800) 669-4000 or TTY (800) 669-6820. Rather than receiving a Right Go to our website at and download a copy of a blank Intake Form.Fillit out and email it to us at contact.center@dfeh.ca.gov or mail it to: 2218 KausenDrive, Suite 100; Elk Grove, CA 95758. or mail it to: 2218 Kausen Drive, Suite 100;95758. You may also obtain a Right-to-Sue notice using our online system at www.dfeh.ca.gov . After you have submitted your form, we will send you a Right-to-Sue letter with the information you provided. American LegalNet, Inc. www.FormsWorkFlow.com CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING RIGHT-TO-SUE Your submission of this document acknowledges that you have read and agree to the DFEH222s Privacy Policy. By submitting this document, you are declaring under penalty of perjury under the laws of the State of California that to the best of your knowledge all information stated is true and correct, except matters stated on information and belief, which you believe to be true. DFEH CASE NUMBER (IF APPLICABLE): COMPLAINANT: NAME: TELEPHONE NUMBER: ADDRESS: EMAIL ADDRESS: CITY/STATE/ZIP: RESPONDENT: NAME: TELEPHONE NUMBER: ADDRESS: CITY/STATE/ZIP: NUMBER OF EMPLOYEES: TYPE OF EMPLOYER: American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 3 of 14 ADD CO-RESPONDENT: NAME: TITLE: ADDRESS: TELEPHONE NUMBER: ADD CO-RESPONDENT: NAME: TITLE: ADDRESS: TELEPHONE NUMBER: DATE OF HARM: LAST DATE OF HARM (Month/Day/Year): American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 4 of 14 1.I ALLEGE THAT I EXPERIENCED:Discrimination Harassment BECAUSE OF MY ACTUAL OR PERCEIVED: Age (40 and over) Ancestry Association with a member of a protected class Baby Bonding Leave (employers of 20-49 people) Criminal History Color Disability (physical or mental) Family Care or Medical Leave (CFRA) Gender Identity or Expression Genetic Information or Characteristic Marital Status Medical Condition (cancer or genetic characteristic) Military and Veteran Status National Origin (includes language restrictions) Race Religious creed (includes dress and grooming practices) Sex/Gender Sexual harassment 226 hostile environment Sexual harassment 226 quid pro quo Sexual orientation Other (specify) American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 5 of 14 AS A RESULT, I WAS: Asked impermissible non-job-related questions Baby Bonding Leave (employers of 20-49 people) Demoted Denied accommodation for pregnancy Denied accommodation for religious beliefs Denied any employment benefit or privilege Denied employer paid health care while on pregnancy disability leave Denied equal pay Denied Family Care or Medical Leave (CFRA) Denied hire or promotion Denied or forced to transfer Denied reasonable accommodation for a disability Denied the right to wear pants Denied a work environment free of discrimination and/or retaliation Denied work opportunities or assignments Forced to quit Laid off Reprimanded Suspended Terminated Other (specify) I ALLEGE THAT I EXPERIENCED: Retaliation BECAUSE I: Reported or resisted any form of discrimination or harassment Participated as a witness in a discrimination or harassment complaint Requested or used baby bonding leave (employers of 20-49 people) Requested or used pregnancy disability related accommodation Requested or used leave under the California Family Rights Act or FMLA Requested or used a disability-related accommodation Requested or used a religious accommodation Reported patient abuse (hospital employees only) American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 6 of 14 AS A RESULT I WAS: Asked impermissible non-job-related questions Demoted Denied accommodation for pregnancy Denied accommodation for religious beliefs Denied baby bonding leave (employers of 20-49 people) Denied any employment benefit or privilege Denied employer paid health care while on pregnancy disability leave Denied equal pay Denied Family Care or Medical Leave (CFRA) Denied hire or promotion Denied or forced to transfer Denied reasonable accommodation for a disability Denied the right to wear pants Denied a work environment free of discrimination and/or retaliation Denied work opportunities or assignments Forced to quit Laid off Reprimanded Suspended Terminated Other (specify) 2.Do you have an attorney who agreed to represent you in this matter?Yes No If yes, please provide the attorney222s contact information.COMPLAINANT222S REPRESENTATIVE INFORMATION Attorney Name: Attorney Firm Name: Attorney Address: Attorney City, State, and Zip: American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 7 of 14 3.Briefly describe what you believe to be the reason(s) for the discrimination, harassment, orretaliation. (Optional) American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 8 of 14 VERIFICATION PAGE 226 THIS PAGE MUST BE COMPLETED Before submitting the form, you must verify who you are and whether you are submitting this information for yourself or someone else. Verifier Name: Verifier's Relationship to Complainant: Verifier's City and State: By submitting this document, you are declaring under penalty of perjury under the laws of the State of California that to the best of your knowledge all information stated is true and correct, except matters stated on information and belief, which you believe to be true. American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 9 of 14 DEMOGRAPHIC INFORMATION THIS INFORMATION IS OPTIONAL AND IS ONLY USED FOR STATISTICAL PURPOSES. Primary Language: Age: GENDER: Male Female Other MARITAL STATUS: Single Married Cohabitation Divorced RACE:American Indian, Native American or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Ethnicity:Hispanic or Latino Non-Hispanic or Latino NATIONAL ORIGIN:Afghani American [U.S.A] Asian Indian Bangladeshi Cambodian Canadian Chinese Cuban Dominican Egyptian English Ethiopian Fijian Filipino German Ghanaian Guamanian Haitian Hawaiian Hmong Indonesian Iranian Iraqi Irish Israeli Italian Jamaican Japanese Korean Laotian Lebanese Malaysian Mexican Nigerian Other Other African Other Asian Other Caribbean Other European Other Hispanic/Latino Other Middle Eastern Pakistani Puerto Rican Salvadoran Samoan Sri Lankan Syrian Taiwanese Thai Tongan Vietnamese American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 10 of 14 DEMOGRAPHIC INFORMATION THIS INFORMATION IS OPTIONAL AND IS ONLY USED FOR STATISTICAL PURPOSES. DISABILITY: AIDS or HIV Blood / Circulation Brain / Nerves / Muscles Digestive / Urinary / Reproduction Hearing Heart Limbs [Arms / Legs] Mental Sight Speech / Respiration Spinal / Back / Respiration Other Disability RELIGION: Agnostic Atheist Bahai Buddhism Catholicism Christianity Confucianism Hinduism Islam Jehovah's Witness Judaism Neo-Paganism Nonreligious Protestantism Primal-indigenous Quakers Rastafarianism Spiritism Shinto Sikhism Taoism Unitarian-Universalism Zoroastrianism Other American LegalNet, Inc. www.FormsWorkFlow.com Right-to-Sue Revised 12/2017 Page 11 of 14 CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT & HOUSING PRIVACY POLICY The California Department of Fair Employment & Housing (DFEH) has adopted this Privacy Policy, effective January 1, 2017. DFEH values the security and privacy of your personal information and is committed to protecting your privacy rights. The DFEH seeks only to collect relevant personal information that enables us to assist you in investigating and resolving complaints of discrimination as prescr