UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT , Plaintiff, v. , Defendant(s). COMPLAINT FOR EMPLOYMENT DISCRIMINATION Case No. (To be supplied by the Court) 1. Plaintiff resides at the following location: 2. Defendant(s) reside(s) at the following location [Attach additional sheets if more space is required]: 3. This action is brought pursuant to [Check all spaces that apply to the type of claim(s) you wish to assert against the Defendant(s)]: Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. �� 2000e, et seq., for employment discrimination on the basis of race, color, religion, sex, or national origin. Jurisdiction is specifically conferred on this Court by 42 U.S.C. � 2000e-5(f). Equitable and other relief is sought under 42 U.S.C. � 2000e-5(g) and the Civil Rights Act of 1991, 42 U.S.C. � 1981a. Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. �� 621, et seq., for employment discrimination based upon age. Jurisdiction is alleged pursuant to 28 U.S.C. �� 1331, 1337, and/or 1343. Equitable and other relief is sought under 29 U.S.C. �� 626(b) and (c) or �� 633a(b) and (c). My Year of Birth is: . American LegalNet, Inc. www.FormsWorkFlow.com Rehabilitation Act of 1973, as amended, 29 U.S.C. �� 701, et seq., for employment discrimination on the basis of a disability against an employer which constitutes a program or activity receiving Federal financial assistance. Jurisdiction is asserted under 28 U.S.C. �� 1331, 1337 and/or 1343. Equitable and other relief is sought under 29 U.S.C. � 794a. Americans with Disabilities Act of 1990, as amended, 42 U.S.C. �� 12101, et seq., for employment discrimination on the basis of a disability against a private employer. Jurisdiction is specifically conferred on this Court by 42 U.S.C.� 2000e-5(f). See 42 U.S.C. � 12117(a). Equitable and other relief is sought pursuant to 42 U.S.C. � 2000e-5(g). Id. 4. The acts complained of in this suit concern [Check all spaces that are applicable to your claim(s)]: (A) Failure to hire me. I was refused a job on the following date(s): . (B) Termination of my employment. I was terminated from my employment on the following date: . (C) Failure to promote me. I was refused a promotion on the following date(s): . (D) Other acts as specified below: 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. The conduct of the Defendant(s) was discriminatory because it was based upon: race [ ], color [ ], religion [ ], sex [ ], age [ ], national origin [ ] or disability [ ]. [Please check all applicable bases for your claim of discrimination and explain further, if necessary]: 6. The facts surrounding my claim of employment discrimination are as follows [Attach additional sheets, if necessary]: 7. The approximate number of persons who are employed by the Defendant . employer I am suing is: 8. period: The alleged discrimination occurred on or about the following date(s) or time . 3 American LegalNet, Inc. www.FormsWorkFlow.com 9. I filed charges with the: Equal Employment Opportunity Commission Connecticut Commission on Human Rights and Opportunities 10. The Equal Employment Opportunity Commission issued a Notice of Right to Sue . letter (copy attached), which I received on or about the following date: [NOTE: If you filed charges with the EEOC or the CHRO, you MUST attach a copy of the Notice of Right to Sue letter for this Court to consider your claim(s). Failure to do so may result in delaying consideration of your claim(s).] 11. The EEOC or the CHRO determined that there was no probable cause to believe that discrimination occurred. My reasons for questioning that determination are as follows [Attach additional sheets, if necessary]: 12. If relief is not granted, I will be irreparably denied rights secured under the law(s) referred to in Item Number 3, above. 13. WHEREFORE, Plaintiff(s) pray(s) that: The Court grant such relief as may be deemed appropriate, including [NOTE: While all of the forms of relief listed below may not be available in a particular action, you should place a check next to each form of relief you seek.): Injunctive orders (specify the type of injunctive relief sought): ; Backpay; 4 American LegalNet, Inc. www.FormsWorkFlow.com Reinstatement to my former position; Monetary damages (specify the type(s) of monetary damages sought): ; Other (specify the nature of any additional relief sought, not otherwise provided for on this form): ; AND costs and attorneys' fees. JURY DEMAND I hereby DO __ DO NOT __ demand a trial by jury. ______________________________ Plaintiff's Original Signature _____________________________ Original signature of attorney (if any) ______________________________ Printed Name and address Printed Name and address () Attorney's telephone () Plaintiff's telephone Email address if available Dated: Email address if available 5 American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION UNDER PENALTY OF PERJURY The undersigned declares under penalty of perjury that he/she is the plaintiff in the above action, that he/she has read the above complaint and that the information contained in the complaint is true and correct. 28 U.S.C. � 1746; 18 U.S.C. � 1621. Executed at _________________________ on ________________________. (location) (date) ________________________________ Plaintiff's Original Signature (Rev. 3/23/16) 6 American LegalNet, Inc. www.FormsWorkFlow.com