STATE OF CALIFORNIA PUBLIC EMPLOYMENT RELATIONS BOARD UNFAIR PRACTICE CHARGE DO NOT WRITE IN THIS SPACE: Case No: Date Filed: INSTRUCTIONS: File the original and one copy of this charge form in the appropriate PERB regional office (see PERB Regulation 32075), with proof of service attached to each copy. Proper filing includes concurrent service and proof of service of the charge as required by PERB Regulation 32615(c). All forms are available from the regional offices or PERB's website at www.perb.ca.gov. If more space is needed for any item on this form, attach additional sheets and number items. IS THIS AN AMENDED CHARGE? 1. CHARGING PARTY: a. Full name: b. Mailing address: c. Telephone number: d. Name and title of person filing charge: Telephone number: e. Bargaining unit(s) involved: Fax No.: E-mail Address: YES If so, Case No. EMPLOYEE ORGANIZATION EMPLOYER NO PUBLIC 1 EMPLOYEE 2. CHARGE FILED AGAINST: (mark one only) a. Full name: b. Mailing address: c. Telephone number: d. Name and title of agent to contact: Telephone number: EMPLOYEE ORGANIZATION EMPLOYER E-mail Address: Fax No.: 3. NAME OF EMPLOYER (Complete this section only if the charge is filed against an employee organization.) a. Full name: b. Mailing address: 4. APPOINTING POWER: (Complete this section only if the employer is the State of California. See Government Code section 18524.) a. Full name: b. Mailing address: c. Agent: ________________________ An affected member of the public may only file a charge relating to an alleged public notice violation, pursuant to Government Code section 3523, 3547, 3547.5, or 3595, or Public Utilities Code section 99569. PERB-61 (7/22/2014) American LegalNet, Inc. www.FormsWorkFlow.com 1 SEE REVERSE SIDE 5. GRIEVANCE PROCEDURE Are the parties covered by an agreement containing a grievance procedure which ends in binding arbitration? Yes _______ No _________ 6. STATEMENT OF CHARGE a. The charging party hereby alleges that the above-named respondent is under the jurisdiction of: (check one) Educational Employment Relations Act (EERA) (Gov. Code sec. 3540 et seq.) Ralph C. Dills Act (Gov. Code sec. 3512 et seq.) Higher Education Employer-Employee Relations Act (HEERA) (Gov. Code sec. 3560 et seq.) Meyers-Milias-Brown Act (MMBA) (Gov. Code sec. 3500 et seq.) Los Angeles County Metropolitan Transportation Authority Transit Employer-Employee Relations Act (TEERA) (Pub. Utilities Code sec. 99560 et seq.) Trial Court Employment Protection and Governance Act (Trial Court Act) (Article 3; Gov. Code sec. 71630 ­ 71639.5) Trial Court Interpreter Employment and Labor Relations Act (Court Interpreter Act) (Gov. Code sec. 71800 et seq.) In-Home Supportive Services Employer-Employee Relations Act (Gov. Code, § 110000 et seq.) b. The specific Government or Public Utilities Code section(s), or PERB regulation section(s) alleged to have been violated is/are: c. For MMBA, Trial Court Act and Court Interpreter Act cases, if applicable, the specific local rule(s) alleged to have been violated is/are (a copy of the applicable local rule(s) MUST be attached to the charge): d. Provide a clear and concise statement of the conduct alleged to constitute an unfair practice including, where known, the time and place of each instance of respondent's conduct, and the name and capacity of each person involved. This must be a statement of the facts that support your claim and not conclusions of law. A statement of the remedy sought must also be provided. (Use and attach additional sheets of paper if necessary.) DECLARATION I declare under penalty of perjury that I have read the above charge and that the statements herein are true and complete to the best of my knowledge and belief and that this declaration was executed on ____________________________ (Date) at . (City and State) _________________________________________________________________________________________________________ (Type or Print Name) (Signature) Title, if any: ______________________________________________________ Mailing address: _________________________________________________________________________________________ _______________________________________________________________________________________________________ Telephone Number: _______________________________ E-Mail Address: _______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com PERB-61 (7/22/2014) PROOF OF SERVICE I declare that I am a resident of or employed in the County of State of _________________. I am over the age of 18 years. The name and address of my residence or business is , . On (Date) (Description of document(s) continued) , I served the (Description of document(s)) on the parties listed below (include name, address and, where applicable, fax number) by (check the applicable method or methods): ___ placing a true copy thereof enclosed in a sealed envelope for collection and delivery by the United States Postal Service or private delivery service following ordinary business practices with postage or other costs prepaid; ___ personal delivery; ___ facsimile transmission in accordance with the requirements of PERB Regulations 32090 and 32135(d). (Include here the name, address and, where applicable, fax number of the Respondent and any other parties served.) I declare under penalty of perjury that the foregoing is true and correct and that this declaration was executed on (Date) , at (City) (State) . (Type or print name) (Signature) American LegalNet, Inc. www.FormsWorkFlow.com