(Del. Rev. 5/2014) Pro Se Employment Discrimination Complaint IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE _________________________________________ _________________________________________ (Name of Plaintiff or Plaintiffs) v. _________________________________________ _________________________________________ (Name of Defendant or Defendants) Civ. Action No.__________________ (To be assigned by Clerk's Office) COMPLAINT FOR EMPLOYMENT DISCRIMINATION (Pro se) Jury Demand? "Yes "No 1. This action is brought pursuant to (check all spaces that apply): " " " 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. Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. §§ 621, et seq., for employment discrimination on the basis of age. My year of birth is:_____________. Rehabilitation Act of 1973, as amended, 29 U.S.C. §§ 701, et seq., for employment discrimination on the basis of a disability by an employer which constitutes a program or activity receiving federal financial assistance. Americans with Disabilities Act of 1990, as amended, 42 U.S.C. §§ 12101, et seq., for employment discrimination on the basis of disability. " 2. Plaintiff resides at _______________________________________________________________ (Street Address) ____________________________________________________________________________________________ (City) (County) (State) (Zip Code) _____________________________________. Attach additional sheets if more than one Plaintiff. (Area Code) (Phone Number) Defendant resides at, or its business is located at _______________________________________ (Street Address) ____________________________________________________________________________________________.( (County) (State) (Zip Code) City) 3. Attach additional sheets if more than one Defendant. 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. The discriminatory conduct occurred in connection with plaintiff's employment at, or application to be employed at, defendant's _____________________________________________ place of business (Defendant's Name) located at ____________________________________________________________________________________ (Street Address) ____________________________________________________________________________________________.( City) (County) (State) (Zip Code) 5. 6. 7. The alleged discriminatory acts occurred on _________, ________________,_______________. (Day) (Month) (Year) The alleged discriminatory practice " is " is not continuing. On ___________, ______________________,____________________, Plaintiff filed charges (Year) (Day) ( Month) with the Department of Labor of the State of Delaware: ______________________________________________, (Agency) ____________________________________________________________________________________________ (Street Address) (City) (County) ________________________________________________, regarding defendant's alleged discriminatory conduct. (State) (Zip Code) On ___________, ______________________,____________________, Plaintiff filed charges (Day) ( Month) (Year) with the Equal Employment Opportunity Commission of the United States regarding defendant's alleged discriminatory conduct. 9. The Equal Employment Opportunity Commission issued the attached Notice-of-Right-to-Sue 8. letter which was received by plaintiff on: ___________, ______________________, __________________. (Day) (Month) (Year) (NOTE: ATTACH NOTICE-OF-RIGHT-TO-SUE LETTER TO THIS COMPLAINT.) 10. The alleged discriminatory acts, in this suit, concern: A. " Failure to employ plaintiff. B. " Termination of plaintiff's employment. Plaintiff was terminated from employment on the following date: ______________________________. C. " Failure to promote plaintiff. Plaintiff was refused a promotion on the following date: ______________________________. D. " Other acts (please specify):________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 11. ____________________________________________________________________ The conduct of Defendant(s) was discriminatory because it was based on (check all that apply): 2 American LegalNet, Inc. www.FormsWorkFlow.com A. B. C. D. E. F. G. 12. " " " " " " " Plaintiff's race Plaintiff's color Plaintiff's sex Plaintiff's religion Plaintiff's national origin Plaintiff's age Plaintiff's disability A copy of the charges filed with the Department of Labor of the State of Delaware and/or the Equal Employment Opportunity Commission is attached to this complaint and is submitted as a brief statement of the facts of plaintiff's claim. (NOTE: ATTACH A COPY OF THE CHARGES FILED WITH THE DEPARTMENT OF LABOR OF THE STATE OF DELAWARE AND/OR THE EQUAL EMPLOYMENT OPPORTUNITY COMMISSION OF THE UNITED STATES TO THIS COMPLAINT.) THEREFORE, Plaintiff asks the Court to grant such relief as may be appropriate, including but not limited to (check all that apply): A. " Injunctive relief (specify what you want the Court to order): _______________________ ______________________________________________________________________________. B. " Back pay. C. " Reinstatement to former position. D. " Monetary damages in the amount of ____________________________. E. " That the Court appoint legal counsel. F. " Such relief as may be appropriate, including costs and attorney's fees. G. " Other (specify): _________________________________________________________. I/We declare under penalty of perjury that the foregoing is true and correct. Dated: __________________________ ____________________________________________ (Signature of Plaintiff) _____________________________________________ (Signature of additional Plaintiff) NOTICE Federal Rule of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to electronic court files. Under this rule, papers filed with the court should not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number. A filing may include only: the last four digits of a social security number; the year of an individual's birth; a minor's initials; and the last four digits of a financial account n