UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MICHIGAN Name of Plaintiff(s) Civil No. ____________________ (To be supplied by the Clerk of the Court) vs. Name of Defendant(s) INSTRUCTIONS FOR FILLING OUT THIS FORM: If you wish to file a lawsuit for the violation of your civil rights you are the plaintiff . The person, employer, company, union, or employment agency you sue is the defendant . If there is more than one plaintiff or defendant , each must be identified by name and address. Each plaintiff must also state the facts of the discriminatory act unless the facts are the same for all plaintiff s. To begin a lawsuit you must file a complaint with the court. This form is to help you file a complaint under Title VII of the Civil Rights Act of 1964 , the Equal Pay Act of 1963 , or both. This form will assist you in following the Federal Rules of Civil Procedure for filing the complaint in United States District Court. Title VII prohibits discrimination on the basis of race, color, sex, religion, or national origin. To file suit under Title VII fill out t he part of this complaint marked COUNT I - TITLE VII. For Title VII suits you should attach a copy of the EEOC "Right to Sue" letter. If your Title VII claim is based on the fact that different wages are paid to employees doing similar jobs and the difference betw een the employees is their sex, then you may have an additional claim under the Equal Pay Act of 1963. To file a complaint under the Equal Pay Act, fill out the part of the form marked COUNT II - EQUAL PAY ACT. If a claim violates the Equal Pay Act it will also violate Title VII. A Title VII violation, however, does not necessarily violate the Equal Pay Act. The Equal Pay Act prohibits only pay differences because of sex. 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 some other similar explanation. If you need help ask the Clerk at the filing desk. Please print legibly. American LegalNet, Inc. www.FormsWorkFlow.com COMPLAINT PARTIES 1. Plaintiff' s address is: street city ( zip code 2. county ) phone number state Defendant' s address is: street city ( zip code county ) phone number state COUNT I - TITLE VII NATURE OF PROCEEDINGS 3. Plaintiff seeks legal and equitable relief for the denial of certain rights secured by the Civil Rights Act of 19 64 , codified as 42 USC Sections 20 00 e to 2 00 0e-1 7. Such relief is authorized by 4 2 USC Section 2000e-5(g). JURISDICTION 4. This Court has jurisdiction pursuant to 4 2 USC Section 2000e-5(f )(1)(3). ADDRESS 5. Is the address where the discriminatory act(s) took place the same address as for defendant? _____ yes _____ no. If different from the defendant' s address, the discriminatory act(s) took place at: street cit y ( zip code county ) phone number stat e American LegalNet, Inc. www.FormsWorkFlow.com FACTS If you were not hired because of your race, color, sex, religion, or national origin, please complete the following. Refusal to Hire 6. Provide a brief statement of the facts to include the following: A. Date of application B. If not hired, the date of refusal to hire C. If you were not hired because of your sex, race, color, religion, or national origin, please list the names (if Known) of other applicants who were hired and their sex, race, religion, or national origin (whichever is applicable to your case): If you were treated differently than other employees because of your race, color, sex, religion or national origin, please complete the following: Difference in Terms and Conditions of Employment Because of Race, Color, Sex, Religion, or National Origin 7. Provide a brief statement of the facts to include the following: A. Job position plaintiff held at time of discharge, demotion, denial of promotion or job bid, denial or difference in pay or benefits, or other discriminatory act: B. Date the act(s) occurred: C. Was there a general layoff or reduction in force (if you know )? ______ yes ______ no D. Rate of pay when this occurred $ E. Name of any individual who was treated differently than you because of your race, color, sex, religion, or national origin (if known): F. The individual's race, color, sex, religion, or national origin (if known) who was treated differently from you: per hour/ per week (please circle) American LegalNet, Inc. www.FormsWorkFlow.com G. Sexual harassment consisted of the following acts, by the following named individuals: Factual Statement The following is plaintiff's account of the facts: CAUSE OF ACTION 8. Defendant violated plaintiff' s civil rights by the following discriminatory act(s): A._____Failure to hire plaintiff; B._____Termination of plaintiff's employment; C._____Demotion of plaintiff ; D._____Denial of promotion or job bid to plaintiff ; E._____Sexual Harassment; F._____Denial of the same terms and conditions of employment given to ot her employees but denied plaintiff because of race, color, sex, religion or national origin; G._____Other Act s (please specify ) 9. Defendant, in committing the above acts, has violated Title VII of the Civil Rights Acts of 1964 because of plaintiff 's (check the correct lett er(s)): A._____race e B._____color C._____sex (includes harassment and pregnancy/maternity) D._____religion E._____national origin American LegalNet, Inc. www.FormsWorkFlow.com 10. Charges were filed with the Equal Employment Opportunity Commission on (state the date or best estimate): Attach a copy of the Charge you filed with the Equal Employment Opportunity Commission. 11. Charges were filed with the Michigan Department of Civil Rights on (state the date or best estimate): . Attach a copy of the Charge you filed with the Michigan Department of Civil Rights. STATUTORY PREREQUISITE 12. Plaintif f received a "Right to Sue" letter from t he Equal Employment Opportunit y Commission on (insert date) 90-day period as required by 42 USC Section 20 00e-5. Attach a copy of "Right to Sue" letter. REQUEST FOR APPOINTMENT OF ATTORNEY If you have been unable to get an attorney to take your case and you want the court to appoint counsel for you, please complete the following: 13. Plaintiff has done the following things in an effort to obtain counsel: 14. Plaintiff has been unable to retain counsel and requests the court to appoint an attorney. _____ yes _____ no. RELIEF Check applicable letter(s). 15. Plaintiff requests the following: A._____That all fees, costs or security be waived; B._____That the Court grant such relief as may be appropriate, including injunctive orders, damages, costs and attorney' s fees; C._____That the Court grant reinstatement where appropriate. American LegalNet, Inc. www.FormsWorkFlow.com COUNT II - EQUAL PAY ACT NATURE OF PROCEEDINGS 16. Plaintiff seeks relief for the denial of certain rights secured by the Equal Pay Act of 1963, codified as 29 USC Section 206(d). Such relief is authorized under 29 USC Section 62 6(b). JURISDICTION 17. This Court has jurisdiction pursuant to 2 9 USC Section 216(b). ADDRESS 18. Is the address where the discriminatory act(s) took place the same address as for defendant ? _____ yes _____ no. If different from the defendant' s address, the discriminatory act(s) took place at: street cit y county ( zip code state ) phone number FACTS 19. Provide a brief statement of the facts to include the follow ing: A. Job position plaintiff held at the time when the pay discrimination occurred B. Rate of pay at t ime this occurred $ C. Names and job positions held by individuals who were paid more than plaintiff because of that individual' s sex per hour/per week (please circle) The following is plaintiff's account of the facts: American LegalNet, Inc. www.FormsWorkFlow.com CAUSE OF ACTION 20. By committing the above acts defendant has violated the Equal Pay Act of 1963 by using sex as a determining factor for pay. 21. Defendant's conduct was willful. 22. Plaintiff filed charges with the Equal Employment Opportunity Commission on (state the date or best estimate) . Attach a copy of the Charge you filed with the Equal Employment Opportunity Commission. 23. Plaintiff filed charges with the Michigan Department of Civil Rights on (state the date or best estimate) . Attach a copy of the Charge you filed with the Michigan Department of Civil Rights. STATUTORY PREREQUISITE 24. This suit has been filed wit hin three years of the wilful discriminatory act. JURY TRIAL 25. Plaintiff requests a jury trial. _____ Yes _____ No RELIEF Check applicable letters. 26. Plaintiff requests the following: A._____ That all fees, costs or security be waived; B._____ That the Court grant such relief as may be appropriate, including liquidated damages, costs and attorney' s fees. DATED: Signature of Plaintiff updated 11/1/2010 American LegalNet, Inc. www.FormsWorkFlow.com