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Civil Complaint Pursuant To Title VII Of Civil Rights Act Of 1964 Form. This is a Kansas form and can be use in District Court Federal.
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Tags: Civil Complaint Pursuant To Title VII Of Civil Rights Act Of 1964, Kansas Federal, District Court
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF KANSAS
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(Enter above the full name of the Plaintiff(s)
vs.
Name
Street and number
City
State
Case Number:
Zip Code
(Enter above the full name and address of the
Defendant in this action - list the name and address
of any additional defendants on the back side of
this sheet).
CIVIL COMPLAINT PURSUANT TO
TITLE VII OF THE
CIVIL RIGHTS ACT OF 1964
or
29 U.S.C. § 621-634(b)
(Age Discrimination in Employment Act)
or
42 U.S.C. § 12111 et seq.
(Americans With Disabilities Act)
Mark the statute that you are filing this complaint under:
_____ Title VII of the Civil Rights Act of 1964.
_____ 29 U.S.C. § 621-634 (b) (Age Discrimination in Employment Act)
_____ 42 U.S.C. § 12111 et. seq. (Americans With Disabilities Act)
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1.
Plaintiff resides at:__________________________________________________
__________________________________________________________________
2.
Defendant employer(s) reside or can be served with process at the addresses set forth
in the caption above.
3.
This Action is brought for employment discrimination, pursuant to one or both of the
following laws:
a.
b.
c.
_____ Title VII of the Civil Rights Act of 1964 for employment discrimination.
_____ Age Discrimination in Employment Act of 1967, codified at 29 U.S.C.
§ 621-634(b), as amended, for employment discrimination based on
age;
_____ Americans With Disabilities Act, codified at 42 U.S.C. § 12111 et.
seq., for employment discrimination based on disability.
Jurisdiction is conferred on this court pursuant to 29 U.S.C. § 626(c)(1), 42 U.S.C. § 2000e-5, or 42
U.S.C. § 12117. If the plaintiff is a federal employee, jurisdiction is conferred on this court pursuant to
29 U.S.C. § 633a(c).
4.
Venue is invoked pursuant to 28 U.S.C. § 1391.
5.
Defendant’s conduct is discriminatory with respect to the following:
a.
_____ My race or color, which is________________________________.
b.
_____ My religion, which is ___________________________________.
c.
_____ My sex, which is _____ male; _____ female.
d.
_____ My national origin, which is ______________________________.
e.
_____ My age, in violation of 29 U.S.C. § 623.
f.
_____ My disability or perceived disability, which is ________________.
g.
_____ Other as specified below:
______________________________________________________
______________________________________________________
_____________________________________________________.
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6.
The plaintiff is an employee within the meaning of the above-cited statutes.
7.
If this is an age discrimination case, the plaintiff states the following:
a.
Plaintiff is within the age limits as prescribed by 29 U.S.C. § 631(a).
b.
My age at the time of the alleged discriminatory conduct was __________.
c.
My year of birth is ______________________.
8.
The defendant(s) is (are) an employer, employment agency, or labor organization within
the meaning of 28 U.S.C. § 1343 and 29 U.S. C § 630(b)(c) and (d).
9.
The defendant(s) is (are) engaged in commerce within the meaning of the above-cited
statutes.
10.
The conduct complained of in this action concern:
a.
_____ Failure to employ
b.
_____ Termination of employment
c.
_____ Failure to promote
d.
_____ Unequal terms and conditions of employment
e.
_____ Reduction in wages
f.
_____ Retaliation
g.
_____ Failure to accommodate disability
h.
_____ Other acts as specified below:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
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11.
The facts surrounding my claim of discrimination are:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
(If more space is needed you may attach additional sheets of 8½” X 11" paper.)
12.
The alleged discriminatory conduct occurred on or about ____________________
at _______________________________________________________________.
13.
In accordance with 42 U.S.C. § 2000e-5, 29 U.S.C.§ 626(d) and 29 U.S.C. §
633(b), or 42 U.S.C. § 12117, more than sixty (60) days have elapsed since filing a
charge alleging unlawful discrimination with the Kansas State Division of Human Rights,
the Kansas Commission on Human Rights or the Equal Employment Opportunity
Commission.
14.
In accordance with 28 U.S.C. § 1343 or 29 U.S.C. § 633a(d), of this is an Age
Discrimination action, a thirty (30) day Notice of Intent to File this action has been
given to the Equal Employment Opportunity Commission.
15.
I filed charges with the Kansas State Division of Human Rights or the Kansas State
Commission on Human Rights regarding the alleged discriminatory act on
_______________________________.
16.
I filed charges with the Equal Employment Opportunity Commission regarding the
alleged discriminatory act on _____________________________________.
17.
I filed a Notice of Intent with the Equal Employment Opportunity Commission on
______________________________.
18.
The Equal Employment Opportunity Commission issued a Notice of Right to Sue letter
(copy attached) which was received by me on or about_________________.
19.
If relief is not granted, plaintiff will be irreparably denied the rights secured by the Age
Discrimination in Employment Act of 1967, as amended, by Title VII of the 1964 Civil
Rights Act, as amended, or by the Americans With Disability Act.
Plaintiff demands trial by jury. Yes_____ No _____
20.
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WHEREFORE, plaintiff prays that:
a.
The court grant the relief stated in 42 U.S.C. § 2000e-5, 29 U.S.C. § 633a(c),
or 42 U.S.C. § 12117, including damages in the amount of
$________________.
b.
The court grant such other legal or equitable relief as the court deems just and
proper, including attorney’s fees and costs.
___________________________________
Signature of Plaintiff
___________________________________
Name (Print or Type)
___________________________________
Address
___________________________________
City
State
Zip Code
___________________________________
Telephone Number
DESIGNATION OF PLACE OF TRIAL
Plaintiff designates ( Wichita,
Kansas City or
(circle one location)
Topeka ), Kansas as the location for the
trial in this matter.
Signature of Plaintiff
REQUEST FOR TRIAL BY JURY
Plaintiff requests trial by jury ( yes or no ).
(circle one)
Signature of Plaintiff
Dated:
(Rev. 9/04)
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