MIED ProSe 7 (Rev 5/16) Complaint for Employment Discrimination IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF MICHIGAN (Write the full name of each plaintiff who is filing this complaint. If the names of all the plaintiffs cannot fit in the space above, please write "see attached" in the space and attach an additional page with the full list of names.) v. Case No. _________________________________ (to be filled in by the Clerk's Office) Jury Trial: Yes No (check one) (Write the full name of each defendant who is being sued. If the names of all the defendants cannot fit in the space above, please write "see attached" in the space and attach an additional page with the full list of names.) Complaint for Employment Discrimination American LegalNet, Inc. www.FormsWorkFlow.com MIED ProSe 7 (Rev 5/16) Complaint for Employment Discrimination I. The Parties to This Complaint A. The Plaintiff(s) Provide the information below for each plaintiff named in the complaint. Attach additional pages if needed. Name Street Address City and County State and Zip Code Telephone Number E-mail Address B. The Defendant(s) Provide the information below for each defendant named in the complaint, whether the defendant is an individual, a government agency, an organization, or a corporation. For an individual defendant, include the person's job or title (if known). Attach additional pages if needed. Defendant No. 1 Name Job or Title (if known) Street Address City and County State and Zip Code Telephone Number E-mail Address (if known) Defendant No. 2 Name Job or Title (if known) Street Address City and County State and Zip Code Telephone Number E-mail Address (if known) __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com MIED ProSe 7 (Rev 5/16) Complaint for Employment Discrimination Defendant No. 3 Name Job or Title (if known) Street Address City and County State and Zip Code Telephone Number E-mail Address (if known) Defendant No. 4 Name Job or Title (if known) Street Address City and County State and Zip Code Telephone Number E-mail Address (if known) __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ C. Place of Employment The address at which I sought employment or was employed by the defendant(s) is: Name Street Address City and County State and Zip Code Telephone Number __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com MIED ProSe 7 (Rev 5/16) Complaint for Employment Discrimination II. Basis for Jurisdiction This action is brought for discrimination in employment pursuant to (check all that apply): Title VII of the Civil Rights Act of 1964, as codified, 42 U.S.C. §§ 2000e to 2000e-17 (race, color, gender, religion, national origin). (Note: In order to bring suit in federal district court under Title VII, you must first obtain a Notice of Right to Sue letter from the Equal Employment Opportunity Commission.) Age Discrimination in Employment Act of 1967, as codified, 29 U.S.C. §§ 621 to 634. (Note: In order to bring suit in federal district court under the Age Discrimination in Employment Act, you must first file a charge with the Equal Employment Opportunity Commission.) Americans with Disabilities Act of 1990, as codified, 42 U.S.C. §§ 12112 to 12117. (Note: In order to bring suit in federal district court under the Americans with Disabilities Act, you must first obtain a Notice of Right to Sue letter from the Equal Employment Opportunity Commission.) Other federal law (specify the federal law): Relevant state law (specify, if known): Relevant city or county law (specify, if known): 4 American LegalNet, Inc. www.FormsWorkFlow.com MIED ProSe 7 (Rev 5/16) Complaint for Employment Discrimination III. Statement of Claim Write a short and plain statement of the claim. Do not make legal arguments. State as briefly as possible the facts showing that each plaintiff is entitled to the damages or other relief sought. State how each defendant was involved and what each defendant did that caused the plaintiff harm or violated the plaintiff's rights, including the dates and places of that involvement or conduct. If more than one claim is asserted, number each claim and write a short and plain statement of each claim in a separate paragraph. Attach additional pages if needed. A. The discriminatory conduct of which I complain in this action includes (check all that apply): Failure to hire me. Termination of my employment. Failure to promote me. Failure to accommodate my disability. Unequal terms and conditions of my employment. Retaliation. Other acts (specify): (Note: Only those grounds raised in the charge filed with the Equal Employment Opportunity Commission can be considered by the federal district court under the federal employment discrimination statutes.) B. It is my best recollection that the alleged discriminatory acts occurred on date(s) ________________________________________________________