1 IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS ) ) ) ) ) (Enter above the full name of Plaintiff(s)) ) ) vs. ) ) ) Case Number: Name ) (To be assigned by Clerk) ) ) Street and number ) ) ) City State Zip Code ) (Enter above the full name and address of Defendant in this action - list the name and address of any additional Defendants on the back side of this sheet.) EMPLOYMENT DISCRIMINATION COMPLAINT 1.This employment discrimination lawsuit is based on (check only those 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, gender, or national origin. NOTE: In order to bring suit in federal district court under Title VII, you must first obtain a right-to-sue letter from the Equal Employment Opportunity Commission. Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. '' 621, et seq., for employment discrimination on the basis of age (age 40 or older). NOTE: In order to bring suit in federal district court under the Age Discrimination in Employment Act, you must first file charges with the Equal Employment Opportunity Commission. American with Disabilities Act of 1990, as amended, 42 U.S.C. '' 12101, et seq., for employment discrimination on the basis of disability. NOTE: In order to bring suit in federal district court under the American with American LegalNet, Inc. www.FormsWorkFlow.com 2 Disabilities Act, you must first obtain a right-to-sue letter from the Equal Employment Opportunity Commission. Other (Describe) 2. If you are claiming that the discriminatory conduct occurred at a different location than the address provided for Defendant, please provide the following information: (Street Address) (City/County) (State) (Zip Code) 3. When did the discrimination occur? Please give the date or time period: ADMINISTRATIVE PROCEDURES 4. Did you file a charge of discrimination against Defendant(s) with the Kansas State Division of Human Rights or the Kansas State Commission on Human Rights? Yes Date filed: No 5. Did you file a charge of discrimination against Defendant(s) with the Equal Employment Opportunity Commission or other federal agency? Yes Date filed: No 6. Have you received a Notice of Right-to-Sue Letter? Yes No If yes, please attach a copy of the letter to this complaint. 7. If you are claiming age discrimination, check one of the following: 60 days or more have passed since I filed my charge of age discrimination with the Equal Employment Opportunity Commission. fewer than 60 days have passed since I filed my charge of age discrimination with American LegalNet, Inc. www.FormsWorkFlow.com 3 the Equal Employment Opportunity Commission NATURE OF THE CASE 8.The conduct complained of in this lawsuit involves (check only those that apply): failure to hire me termination of my employment failure to promote me failure to accommodate my disability terms and conditions of my employment differ from those of similar employees retaliation harassment reduction in wages other conduct (specify): Did you complain about this same conduct in your charge of discrimination? Yes No 9.I believe that I was discriminated against because of (check all that apply): my race or color, which is my religion, which is my national origin, which is my gender, which is male; female my disability or perceived disability, which is my age (my birth is: ) other: Did you state the same reason(s) in your charge of discrimination? Yes No 10.State here, as briefly and clearly as possible, the essential facts of your claim. Describespecifically the conduct that you believe is discriminatory and describe how eachdefendant is involved in the conduct. Take time to organize your statement; you may usenumbered paragraphs if you find it helpful. It is not necessary to make legal arguments, orto cite cases or statutes. American LegalNet, Inc. www.FormsWorkFlow.com 4 (Attach additional sheets as necessary). 11.The acts set forth in paragraph 10 of this complaint: are still being committed by Defendant. are no longer being committed by Defendant. may still be being committed by Defendant. 12. Plaintiff: still works for Defendant no longer works for Defendant or was not hired 13.If this is a disability-related claim, did Defendant deny a request for a reasonableaccommodation?Yes No Explain: REQUEST FOR RELIEF As relief from the allegations of discrimination as stated above, Plaintiff prays that the court grant the following relief to Plaintiff: (check any and all that apply) Defendant be directed to employ Plaintiff Defendant be directed to re-employ Plaintiff Defendant be directed to promote Plaintiff Defendant be directed to American LegalNet, Inc. www.FormsWorkFlow.com 5 Injunctive relief (please explain): Monetary damages (please explain): Costs and fees involved in litigating this case As additional relief to make Plaintiff whole, Plaintiff seeks:and such other relief as may be appropriate, including attorney=s fees, if applicable. Signed this day of , 20. Signature of Plaintiff Name (Print or Type) Address City State Zip Code Telephone Number DESIGNATION OF PLACE OF TRIAL Plaintiff designates { [ ] Wichita, [ ] Kansas City, [ ] Topeka}, Kansas as the location for the trial in (Select One Location) this matter. Signature of Plaintiff REQUEST FOR TRIAL BY JURY Plaintiff requests trial by jury. Yes No (Select One) Signature of Plaintiff Dated: (Rev. 10/15) American LegalNet, Inc. www.FormsWorkFlow.com