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EEO Complaint Form Age Discrimination Form. This is a Michigan form and can be use in USDC Western Federal.
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Tags: EEO Complaint Form Age Discrimination, Michigan Federal, USDC Western
COURT
COUNTY . .
. . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
:
:
Index No.
Calendar No.
UNITED STATES DISTRICT COURT
:
JUDICIAL
Plaintiff(s)
WESTERN DISTRICT OF MICHIGAN
_____________
:
-against-
SUBPOENA
:
:
Defendant(s)
:
. . . . . . . Name. of. Plaintiff(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.... . .......
Civil No. ______________
(To be supplied by the
Clerk of the Court)
vs.
THE PEOPLE OF THE STATE OF NEW YORK
TO
Name of Defendant(s)
GREETINGS:
INSTRUCTIONS FOR COMPLETING FORM: If you wish to file a law suit for violation of your civil rights
WE COMMANDage, then youall business and The person, company, or union you sue is the you attend before
because of your YOU, that are the plaintiff. excuses being laid aside, you and each of defendant. To
,
the Honorable a lawsuit you must file a complaint with the court. This form is to help you follow the Federal Rules of
at the
Court
begin
located at
County of Civil Procedure in filing a complaint under the AGE DISCRIMINATION IN EMPLOYMENT ACT OF 1967
(ADEA). on there is more than one plaintiff or20
in room
, If the
day of
, defendant, each must be identified by name and address. recessed
, at
o'clock in the
noon, and at any Each
plaintiff must also state the facts of the discriminatory act unless the facts are the same
or adjourned date,plaintiffs. and give evidence as a witness in this action on the part of the
to testify
for all
You may not be able to fill in every blank. If you are unable to provide the requested information, state
either "unknown" or "not applicable" or other similar explanation. If you need help, ask the Clerk at the filing
desk.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
party on whose behalf this subpoena was issuedPleasemaximum penalty of $50 and all damages sustained as a
for a print legibly.
the
result of your failure to comply.
Witness, Honorable
Court in
County,
COMPLAINT
day of
, one of the Justices of the
, 20
PARTIES
1.
Plaintiff's address is:
(Attorney must sign above and type name below)
street
city
county
zip code
2.
Defendant's address is:
Attorney(s) for
(
)
state
phone number
Office and P.O. Address
street
city
zip code
county
Telephone No.:
(
)
Facsimile No.:
phone number
E-Mail Address:
Mobile Tel. No.:
state
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COURT
COUNTY . .
. . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
:
:
Index No.
Calendar No.
:
JUDICIAL SUBPOENA
Plaintiff(s)OF PROCEEDINGS
NATURE
-against:
3.
Plaintiff seeks legal and equitable relief for the denial of certain rights secured
by the Age Discrimination in Employment Act of 1967, as codified at 29 USC Sections 621:
634. Such relief is authorized under 29 USC Section 626 (b)(c).
:
JURISDICTION
Defendant(s)
:
. . . . . . . . . . . . . .4.. . . . . This .Court. has.jurisdiction. pursuant to 29 USC Section 626(c)(d).
.
.... .... ... ......... ..........
ADDRESS
THE PEOPLE OF THE STATE OF NEW YORK discriminatory act(s) took place the same address as
5.
Is the address where the
TO
for defendant? _____ yes _____ no. If different from the defendant's address, the
discriminatory act(s) took place at:
street
GREETINGS:
city
county
state
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
(
)
zip code
,
the Honorable
at the phone number Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
FACTS
Your failure to comply If youthis subpoena isbecause of your age, please complete. will make you liable to
with were not hired punishable as a contempt of court and
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Refusal to Hire
Witness, Honorable
, one of the Justices of the
Court in
County,
day of
, 20
6.
Provide a brief statement of the facts to include the following:
A.
Date of application
, 20
(Attorney must sign above and type name below)
B.
If not hired, the date of refusal to hire
, 20
C.
If you were not hired because of your age, the names and ages of
Attorney(s) for
other applicants who were hired (if known):
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
2
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COURT
COUNTY . .
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:
:
Index No.
Calendar No.
:
If you were treated differently than other employees because ofJUDICIAL SUBPOENA
your age, please complete the following
Plaintiff(s)
.
-against-
:
:
Difference in Terms and Conditions of
:
Employment Because of Age
Defendant(s)
:
......................................................
7.
Provide a brief statement of the facts to include the following:
A.
Job position plaintiff held at time of discharge, demotion, or other
THE PEOPLE OF THE STATE discriminatory act
OF NEW YORK
TO
B.
GREETINGS:
Date the act(s) occurred
, 20
C.
Was this part of a general layoff or reduction in force (if you know)?
_____ yes _____ no
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
D.
Rate of pay when this occurred $ Court
per hour/per week (please
,
the Honorable
at the
circle) at
located
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
E.
Replacement's name and age (if known)
or adjourned date, to testify and give evidence as a witness in this action on the part of the
F.
Name and age (if known) of any individual who was treated
Your failure to comply differently than you punishableof your age of court and will make you liable to
with this subpoena is because as a contempt
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Factual Statement
Witness, Honorable
The following is plaintiff's day of
account of the facts:
Court in
County,
, 20
, one of the Justices of the
(Attorney must sign above and type name below)
Attorney(s) for
CAUSE OF ACTION P.O. Address
Office and
8.
Defendant in committing the above acts has violated the Age Discrimination in
Employment Act of 1967 in that defendant has discriminated against plaintiff because of
Telephone No.:
plaintiff's age.
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
3
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COURT
COUNTY . .
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:
Index No.
:
Calendar No.
:
JUDICIAL SUBPOENA
Plaintiff(s)
Defendant's conduct was willful.
-against:
10.
Charges were filed with the Equal Employment Opportunity Commission on
(state the date or best estimate):
, 20
:
9.
:
Attach a copy of the Charge you filed with the Equal Employment Opportunity Commission.
Defendant(s)
:
......................................................
11.
Charges were filed with the Michigan Department of Civil Rights on (state the
date or best estimate):
, 20
THE PEOPLE OF THE STATE OF NEW YORK
Attach a copy of the Charge you filed with the Michigan Department of Civil Rights.
TO
GREETINGS:
STATUTORY PREREQUISITE
WE COMMAND YOU,has complied with 29 USC being laid aside, youin that plaintiff filed a before
12.
Plaintiff that all business and excuses Section 626(d)(2) and each of you attend
,
the Honorable with the Equal Employment Opportunity Commission (check appropriate letter):
at the
Court
charge
located at
County of
in room
, on the
day of
, after , at
o'clock in the
noon,
A._____Within 300 days 20 the unlawful incident occurred; orand at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
B._____Within 30 days of notice of the end of proceedings under State law.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Note
result of your failure to comply. to plaintiff: the time limit for filing is A or B, whichever is earlier.
Witness, Honorable
, one of the it has been at
13.
Plaintiff has complied with 29 USC Section 626(d) in that Justices of the least 60
Court in days since charges were day of
County,
, 20
filed with the Equal Employment Opportunity Commission.
14.
Plaintiff was born on
day
month
year
and has complied with
(Attorney old at above and the discriminatory act
29 USC Section 631 in that Plaintiff was at least 40 yearsmust sign the timetype name below)
took place.
Attorney(s) for
JURY TRIAL
15.
Plaintiff requests a trial by jury as provided in 29 USC Section 626(c)(2).
Office and
_____ Yes _____ No P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
4
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COURT
COUNTY . .
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:
Index No.
:
RELIEF
16.
Plaintiff(s)
Plaintiff requests the following:
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
:
Check applicable letters
:
A._____ That all fees, costs or security attendant to this suit be waived;
Defendant(s)
:
......................................................
B._____ That the Court grant such relief as may be appropriate, including
injunctive orders, damages, costs and attorney's fees;
THE PEOPLE OF THE STATE OF NEW YORK
C._____ That the Court grant reinstatement where appropriate.
TO
DATED:
GREETINGS:
Signature of Plaintiff
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
5
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