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