UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF GEORGIA ATLANTA DIVISION _____________________________ Plaintiff vs. _____________________________ Defendant : : : : : : : TITLE VII COMPLAIN T 1. Plaintiff resides at _________________________________________________ 2. Defendant(s) names (s) ____________________________________________ Location of principal office(s) of the named defendant(s) ________________________ Nature of defendant(s) business____________________________________________ Approximate number of individuals employed by defendant(s) ____________________ *Note: This is a form complaint provided by the Court for pro se litigants who wish to file an employment discrimination lawsuit. It is not intended to be used for other kinds of cases. American LegalNet, Inc. www.FormsWorkFlow.com 3. 4. This action is brought pursuant to Title VII of the Civil Rights Act of 1964 for employment discrimination. Jurisdiction is specifically conferred on the court by 42 U.S.C. § 2000e-5. Equitable and other relief are also brought under 42 U.S.C. §e-5(g). The acts complained of this suit concern: A. B. C. D. 5. Failure to employ me. Termination of my employment. Failure to promote me. Other (Specifiy) __________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Plaintiff: A. B. 6. ________ ________ ________ ________ ________ ________ presently employed by the defendant. not presently employed by the defendant. The dates of plaintiff’ employment were _________________________. s The reasons plaintiff was given for termination of employment is/are: (1) ________ plaintiff was discharged. (2) ________ plaintiff was laid off. (3) ________ plaintiff left the job voluntarily. Defendant(s) conduct is discriminatory with respect to the following: A. B. C. D. E. ________ ________ ________ ________ ________ my race my religion. my sex. my national origin. Other (specify) ___________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ -2- American LegalNet, Inc. www.FormsWorkFlow.com 7. The name(s), race, sex and the position or title of the individual(s) who allegedly discriminated against me during the period of my employment with the defendant company is/are: 8. Describe the discriminatory actions or events you are complaining of in this lawsuit. Give factual detail, including names and dates concerning what happened. You do not need to refer to any statutes or cite law. -3- American LegalNet, Inc. www.FormsWorkFlow.com 9. The alleged illegal activity took place at ________________________________ 10. A. ________ I have filed a charge with the Equal Employment Opportunity Commission regarding defendant(s). (I have attached a copy of my charge(s) filed with the Equal Employment Opportunity Commission, which are incorporated into this complaint. B. ________ I have not filed a charge. A. ________ I received a Notice of Right-to-Sue letter from the Equal Employment Opportunity Commission on _______________ (date). (I have attached a copy of the Notice of Right-to-Sue which is incorporated into this complaint.) B. ________ I have not received a Notice of Right-to-Sue letter from the Equal Employment Opportunity Commission. 11. 12. State what relief you are seeking from the Court. If you are seeking a monetary award (back pay or damages), state the amount you are seeking. If you are seeking injunctive relief (an order by the Court) issued against the defendant(s) summarize what should be in the order. -4- American LegalNet, Inc. www.FormsWorkFlow.com _____________________________ Date __________________________ Signature of Plaintiff Address: ___________________ __________________________ __________________________ Telephone: _________________ -5- American LegalNet, Inc. www.FormsWorkFlow.com