UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF ILLINOIS ____________________________________ ____________________________________ ____________________________________ ____________________________________ Plaintiff(s) vs. Case No: ________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ Defendant(s) PRO SE COMPLAINT AGAINST EMPLOYMENT DISCRIMINATION, UNDER TITLE VII OF THE CIVIL RIGHTS ACT OF 1964, 42 U.S.C. §§ 2000e-5 I. PREVIOUS PROCEEDINGS BEFORE THE EQUAL EMPLOYMENT OPPORTUNITIES COMMISSION (EEOC) A. Have you filed a charge before the federal Equal Employment Opportunities Commission (EEOC) relating to this claim of employment discrimination? ( ) YES ( ) NO B. If your answer is YES, describe the EEOC proceeding: 1. Parties to the previous EEOC proceeding: Petitioner (s) _________________________________________ ____________________________________________________ ____________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Page 2 Respondent (s) _______________________________________ ____________________________________________________ ____________________________________________________ 2. Location of EEOC office that handled your charge ______________ ______________________________________________________ 3. Docket or case number of your charge: _______________________ 4. Disposition (what was the final result of your charge):___________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ 5. Has EEOC written you a right-to-sue letter (telling you that you have the right to sue in a United States District Court if you are dissatisfied with the disposition of your charge)? ( ) YES ( ) NO 6. Date of filing charge before EEOC: _____________________ 7. Date of disposition by EEOC: __________________________ C. Attach copies of all documents you possess relating to the EEOC proceeding, ESPECIALLY YOUR RIGHT-TO-SUE LETTER. II. PREVIOUS LOCAL, STATE OR FEDERAL PROCEEDINGS OTHER THAN EEOC A. Have you begun other legal proceedings before state or local courts or agencies, or a federal court (but NOT the EEOC) relating to your claim of employment discrimination? ( ) YES ( ) NO 2 American LegalNet, Inc. www.FormsWorkflow.com Page 3 B. If your answer is YES, describe each legal proceeding: 1. Parties to the previous legal proceeding: Plaintiff(s) or petitioner(s) _______________________________ ________________________________________________________ ________________________________________________________ Defendant(s) or respondent(s) ______________________________ ________________________________________________________ ________________________________________________________ 2. Name of court or agency: ________________________________ ________________________________________________________ ________________________________________________________ 3. Docket or case number: _________________________________ 4. Name of the judge or hearing officer: _______________________ ________________________________________________________ 5. Disposition (for example: Was the case dismissed? Who won? Was there an appeal? Is the appeal pending or final? ________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 6. Date of beginning previous proceeding:_____________________ 7. Date of disposition of proceeding:_________________________ NOTE: If there was more than one previous legal proceeding, excluding an EEOC proceeding, describe them on separate sheets of paper. Follow the outline above, label the sheets clearly, and attach them to this pro se complaint. 3 American LegalNet, Inc. www.FormsWorkflow.com Page 4 C. Have you attached separate sheets regarding previous state, local or federal legal proceedings (other than EEOC)? ( ) YES ( ) NO III. PARTIES TO YOUR PRO SE COMPLAINT OF EMPLOYMENT DISCRIMINATION A. Plaintiff(s) 1. Your full name ________________________________________ _______________________________________________________ 2. Your address _________________________________________ _______________________________________________________ 3. Names and addresses of other plaintiffs, if any (You should name other plaintiffs only if they were petitioners with you in a previous EEOC proceeding, or else if EEOC began a previous proceeding on behalf of you and them): __________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ (Use a separate sheet if necessary; label it clearly if so) B. Have you attached a separate sheet naming other plaintiffs? ( ) YES ( ) NO C. Defendant (s) (You should name here the first-named respondent, or else its successor, in the previous EEOC proceeding brought by you or on your behalf): 1. Full name (individual or firm): ___________________________ _______________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com Page 5 2. Business address: ______________________________________ _______________________________________________________ 3. Job position (if individual) _______________________________ _______________________________________________________ 4. Status as an entity (if defendant is a business firm): ( ) Corporation ( ) Partnership ( ) Sole Proprietorship ( ) Other _____________________________________________ (If you do not know this information, and you cannot find out by reasonable means, ask the defendant for it. If the defendant will not tell you, leave this section blank.) 5. Names, business addresses, and job position or entity status of other defendants, if any (you should name additional defendants only if they were named as respondents in a previous EEOC proceeding brought by you or on your behalf): _________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ (Use a separate sheet if necessary; label it clearly if so) D. Have you attached a separate sheet naming other defendants? ( ) YES ( ) NO 5 American LegalNet, Inc. www.FormsWorkflow.com Page 6 IV. STATEMENT OF YOUR CLAIM OF EMPLOYMENT DISCRIMINATION A. Were you: ( ) Not hired? ( ) Discharged? ( ) Suspended? ( ) Demoted? ( ) Denied Promotion? ( ) Denied Wage Increases? ( ) Other (please specify) ________________________________ ______________________________________________________ B. State here as briefly, concisely and clearly as possible the essential facts of your claim. Take time to organize your statement; you may use numbered paragraphs if you find it helpful. Include precisely how each defendant in this action is involved. Include the names of other persons involved who are not defendants; give dates and place. Concentrate on describing as clearly and simply as possible the employment practice you allege to be illegal, and how it discriminated against you. IT IS NOT NECESSARY TO MAKE LEGAL ARGUMENTS OR CITE ANY CASES OR STATUTES. IN MOST CIRCUMSTANCES, THIS ONLY MAKES THE CLAIM OF A LAYMAN MORE DIFFICULT TO UNDERSTAND. AS MUCH AS POSSIBLE, LET THE FACTS SPEAK FOR THEMSELVES. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ DO NOT FEEL COMPELLED TO USE ALL THE SPACE. 6 American LegalNet, Inc. www.FormsWorkflow.com Page 7 V. RELIEF YOU REQUEST Check below what you want the court to do for you. You may make as many checks as you like. ( ) Should you prevail in this lawsuit, award you back pay. ( ) Should you prevail in this lawsuit, reinstate you in your old position. ( ) Should you prevail in this lawsuit, award you certain costs of suit (but not attorneys fees). ( ) Other ___________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ VI. JURY DEMAND ( ) YES ( ) NO Signed this __________ day of _______________________, 20___. ______________________________________ _______________________________________ _______________________________________ (Signature of Plaintiff or Plaintiffs) ADDRESS:_____________________________ _______________________________________ _______________________________________ PHONE NO.:____________________________ 7 American LegalNet, Inc. www.FormsWorkflow.com