UNITED STATES DISTRICT COURT FOR THE CENTRAL DISTRICT OF ILLINOIS ___________________________________ ) ) ___________________________________ ) ) ___________________________________ ) (Name of the plaintiff or plaintiffs) ) ) v. ) ) ___________________________________ ) ) ___________________________________ ) ) ___________________________________ ) (Name of the defendant or defendants) ) CIVIL ACTION NO.___________________ COMPLAINT OF EMPLOYMENT DISCRIMINATION 1. Plaintiff G DOES G DOES NOT demand a jury trial. I. PARTIES 2. The plaintiff is _________________________________________________________, whose street address is___________________________________________________________, (city)_____________________(state)______________(ZIP)________ (Plaintiff's telephone number) (____) ­ ________________________ 3. The defendant is _______________________________________________________, whose street address is ___________________________________________________________, (city)_____________________(state)______________(ZIP)________ (Defendant's telephone number) (____) ­ ________________________ 4. The alleged discrimination occurred at __________________________________________ (city)_____________________(state)_____________ (ZIP)__________ American LegalNet, Inc. www.FormsWorkFlow.com 5. The plaintiff [check one box] G (b)G (c)G (a) was denied employment by the defendant. was hired and is still employed by the defendant. was employed but is no longer employed by the defendant. 6. The defendant discriminated against the plaintiff on or about, or beginning on or about, (month)_____________, (day)________, (year)_________. II. JURISDICTION 7. Jurisdiction over this claim is based on 28 U.S.C. § 1331. Plaintiff alleges that the defendant(s) discriminated against Plaintiff because of Plaintiff's: G Age (The Age Discrimination in Employment Act, 29 U.S.C. § 621) G Color (Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. § 2000e) G Disability (The Americans with Disabilities Act, 42 U.S.C. § 12101 and/or The Rehabilitation Act, 29 U.S.C. § 701) G National Origin (Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. § 2000e) G Race (Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. § 2000e) G Race (42 U.S.C. § 1981) G Religion (Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. § 2000e) G Sex/Gender (Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. § 2000e) G Sex/Gender (Equal Pay Act, 29 U.S.C. § 206) G Use of Leave (Family and Medical Leave Act, 29 U.S.C. § 2611) G Other (list): _____________________________________________________________ 8. Plaintiff G HAS G HAS NOT filed a charge before the United States Equal Employment Opportunity Commission (EEOC) relating to this claim of employment discrimination. [Attach a copy of charge to this complaint.] 9. Plaintiff G HAS G HAS NOT filed a charge before the Illinois Department of Human Rights (IDHR) relating to this claim of employment discrimination. [Attach a copy of charge to this complaint.] 2 American LegalNet, Inc. www.FormsWorkFlow.com 10. Plaintiff G HAS G HAS NOT received a Right to Sue Notice. If yes, Plaintiff's Right to Sue Notice was received on or about (date) ______________________________________. [Attach copy of Notice of Right to Sue to this complaint.] III. FACTS IN SUPPORT OF CLAIM 11. The defendant intentionally discriminated against Plaintiff [check only those that apply]: G (b)G (c)G (d)G (e)G (f)G (a) (g)G (h)G by failing to hire the plaintiff. by terminating the plaintiff's employment. by failing to promote the plaintiff. by failing to stop harassment; by failing to reasonably accommodate the plaintiff's disabilities. by failing to reasonably accommodate the plaintiff's religion. by retaliating against the plaintiff because the plaintiff did something to assert rights protected by the laws; by coercing, intimidating, threatening or interfering with the plaintiff's exercise or enjoyment of rights; with respect to the compensation, terms, conditions, or privileges of employment; other (specify):______________________________________________ (i)G (j) G ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com 12. State here briefly and as clearly as possible the essential facts of your claim. Describe precisely how each defendant in this action is involved. Give dates and places. Concentrate on describing as clearly and simply as possible what employment action or situation you allege to have been illegal and how it violated your rights. It is not necessary to make legal arguments or cite any cases or statutes. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 13. THEREFORE, the plaintiff asks that the court grant the following relief to the plaintiff [check only those that apply] G (b)G (c)G (d)G (e)G (f)G (a) Direct the defendant to hire the plaintiff. Direct the defendant to re-employ the plaintiff. Direct the defendant to promote the plaintiff. Direct the defendant to reasonably accommodate the plaintiff's religion. Direct the defendant to reasonably accommodate the plaintiff's disabilities. Direct the defendant to (specify): _______________________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com ___________________________________________________________________ ___________________________________________________________________ ____________________________