MEMORANDUM TO: Plaintiffs Proceeding Pro Se in Discrimination Lawsuits SUBJ: Forms and Instructions for Filing Suit The forms, instructions, and information you will need to file a discrimination suit in the United States District Court for the Northern District of Mississippi are included in this packet. This packet contains: CHECKLIST. This checklist will help you make sure you have correctly and completely prepared the proper forms for opening your lawsuit. COMPLAINT. The Complaint form must be filled out completely and legibly. All entries must be typewritten or printed clearly. Read the Complaint form completely before you begin filling it out. Gather all the necessary information before you begin completing the form. The Complaint contains numerous check boxes; before you check a selection, make sure the selection pertains to your complaints of legal discrimination. APPLICATION TO PROCEED WITHOUT PREPAYMENT OR SECURITY FOR FEES AND COSTS AND FOR APPOINTMENT OF AN ATTORNEY. You must complete and file this form if you want the court to allow you to proceed without payment of filing fees or liability for costs. The court will use your application to decide whether you are entitled to proceed without prepaying or giving security for fees and costs and whether you are entitled to have a lawyer appointed to represent you. USM FORM 285 AND SUMMONS FORM. You must complete both these forms for each defendant. If you need more than one set of these forms, call or visit our offices. When you have completed all the forms, deliver them in person or by mail to our office nearest you. Use the Checklist to ensure that you have all the necessary paperwork. The Clerk’ Office s staff will fill in the blank next to the words “Civil Action No.” The Clerk's Office cannot give you legal advice. But we can help you with questions about the forms and the processes involved in a discrimination suit. Please visit our offices or call us. American LegalNet, Inc. www.FormsWorkflow.com CHECKLIST FOR PLAINTIFFS FILING DISCRIMINATION LAWSUITS Read the items below carefully and completely. Refer to the COMPLAINT, the REQUEST FOR APPOINTMENT OF ATTORNEY, the APPLICATION TO PROCEED WITHOUT PREPAYMENT OR SECURITY FOR FEES AND COSTS, the USM FORM 285, and the SUMMONS Form. Read carefully every line in every document. Complete all forms clearly and legibly. Review especially carefully all the checkbox selections you chose and the information you printed or typed on the forms. Gather all the papers you are instructed to attach to your forms. Then complete the following checklist: G Did you complete the COMPLAINT and all other forms legibly and completely? G If you received a RIGHT TO SUE LETTER from the EEOC, did you attach the letter and the envelope to your COMPLAINT? G If the EEOC issued a DETERMINATION, did you attach a copy of it to your COMPLAINT? G Do you have the filing fee— $350 cash or postal money order— to deliver to the Clerk’ s Office when you file your lawsuit? If you file an APPLICATION TO PROCEED WITHOUT PREPAYMENT OR SECURITY FOR FEES AND COSTS, the judge will determine whether you may be excused from filing the $350 fee. If the judge denies your application, you will be required to pay the $350 filing fee plus the costs of serving process; if you do not pay the fee and costs, your lawsuit may be dismissed by the judge. G If you do not have the $350 filing fee, did you complete the APPLICATION TO PROCEED WITHOUT PREPAYMENT OR SECURITY FOR FEES AND COSTS form? G Did you complete the USM/285 and the SUMMONS forms for each Defendant? G Do you have all the copies of all the papers you need for commencing your lawsuit? You must have the following at the time you file your lawsuit with the Clerk of the Court: G G Original plus one copy of every form required for your lawsuit. One copy of your COMPLAINT and one copy of your RIGHT TO SUE LETTER (and, if applicable, one copy of the EEOC’ DETERMINATION) for every Defendant s named in your lawsuit. A copy of these documents must be delivered to each Defendant when your Summons is served. American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF MISSISSIPPI Plaintiff(s) v. CIVIL ACTION NO. Defendant(s) COMPLAINT 1. This civil action is commenced by following statutory law (place a check mark in the appropriate box): G , Plaintiff, under the Title VII of the Civil Rights Act of 1964, 42 USC §§ 2000e et seq., for employment discrimination on the basis of race, color, sex (gender, pregnancy, and sexual harassment), religion, or national origin. G The Age Discrimination in Employment Act [ADEA], 29 USC §§ 621 et seq. G The Americans With Disabilities Act [ADA], 42 USC §§ 12102 et seq. G The Equal Pay Act [EPA], 29 USC § 206(d). G The Rehabilitation Act of 1973, 29 USC §§ 791 et seq. (Applicable to federal employees only). 2. Plaintiff's address is (Street or P.O. Box) (City) (State) (ZIP) (Street or P.O. Box) (City) (State) (ZIP) 3. Defendant's address is 4.A. Plaintiff (check one)— G sought employment from the Defendant or, G was employed by Defendant at (City and State) American LegalNet, Inc. www.FormsWorkflow.com 4B. If Defendant is an employer— G At all times relevant to this claim of discrimination, Defendant had employees. (Insert number) 4C. If Defendant is a union— G At all times relevant to this claim of discrimination, Defendant had members. (Insert number) 5A. If the act(s) of discrimination happened on one day only— G The discrimination happened on this date: 5B. If the act(s) of discrimination happened on more than one day— G The discrimination began on this date: date: and ended on this . 6. On or about Plaintiff filed charges against Defendant with the Equal Employment Opportunity Commission [EEOC], charging Defendant with the acts of discrimination stated in paragraph 10 of this Complaint. [Not applicable to federal employees]. 7. On or about the EEOC issued Plaintiff a RIGHT TO SUE LETTER. 8. Plaintiff received the RIGHT TO SUE LETTER on or about . Notice: Attach to this Complaint a copy of your RIGHT TO SUE LETTER and the envelope in which the letter was received by you. 9. (Check one): The EEOC issued a DETERMINATION: G Yes G No Notice: If you checked Yes, attach to this Complaint a copy of the EEOC's DETERMINATION. -2- American LegalNet, Inc. www.FormsWorkflow.com Special Instructions: Please read paragraph 10 carefully and completely before completing. 10. Defendant— (place a check mark in all of the following selections that are applicable to your Complaint) G Failed to employ Plaintiff G Fired Plaintiff G Failed to promote Plaintiff G Harassed Plaintiff G Other (specify clearly and briefly): because of— G Plaintiff's race (state your race ) G Plaintiff's color (state your color ) G Plaintiff's sex (gender, pregnancy, or sexual harassment) (If applicable, state your sex and your claim: ) G Plaintiff's religion (state your religion ) G Plaintiff's national origin (state your national origin G Plaintiff's age (state your date of birth ) ) G Plaintiff's disability (state your disability ) G Plaintiff's earlier complaint of discrimination or opposition to acts of discrimination. (If you are alleging Retaliation, state the acts or events that you claim constitute retaliation: ) The acts or omissions stated above are: G still being committed or omitted by Defendant; or, -3American LegalNet, Inc. www.FormsWorkflow.com G no longer being committed or omitted by Defendant. 11. State specifically and briefly what Defendant, or Defendant's agents, or Defendant's employees did that constitutes discrimination against you personally. Include in your statement specific dates and specific events or acts, and any specific comments or statements made by Defendant, Defendant's agents, or Defendant's employees pertaining to your discrimination claim. 12. State the names of witnesses who would testify for you or on your behalf, and state briefly what they would say. WITNESS'S NAME WHAT THIS WITNESS WOULD SAY -4American LegalNet, Inc. www.FormsWorkflow.com 13. Name all documents that you know of which would support your claim and state briefly what each document says or shows. DOCUMENT WHAT THE DOCUMENT SAYS OR SHOWS 14. (If applicable) Plaintiff has attached to this Complaint a copy of the charge Plaintiff filed with the EEOC. This charge is submitted as a brief statement of the facts supporting this Complaint. 15. Plaintiff requests that the court grant Plaintiff the following relief: G Defendant be ordered to employ Plaintiff G Defendant be ordered to re-employ Plaintiff G Defendant be ordered to promote Plaintiff G Defendant be ordered to -5American LegalNet, Inc. www.FormsWorkflow.com and that the court give Plaintiff such other relief as may be appropriate, including injunctive orders, damages, costs, and attorneys' fees. 16. I declare or certify or verify or state under penalty of perjury that the facts and statements in this Complaint are true and correct. Date: Plaintiff's Signature Plaintiff's Printed Name Plaintiff's Street or P.O. Box Address City State ZIP Plaintiff's Telephone Number -6American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF MISSISSIPPI CIVIL ACTION NO. APPLICATION FOR LEAVE TO FILE SUIT UNDER TITLE VII OF THE CIVIL RIGHTS ACT OF 1964 WITHOUT PAYMENT OF FEES, COSTS, OR SECURITY AND FOR APPOINTMENT OF AN ATTORNEY My name is . I know that there are criminal penalties for making false official statements. With that knowledge, I hereby apply to the United States District Court for the Northern District of Mississippi for appointment of a lawyer and for leave to file suit against (Insert Defendant's Name and Address) under Title VII of the Civil Rights Act of 1964 without payment of fees or costs or giving security therefor. In support of this application, I submit the following information under oath (check appropriate boxes): 1. Marital Status: G Single G Married 2. Dependents: G Spouse G Children (Number: 3. I am a resident of the State of 4. My home address is: G Divorced G Others ) . (Street or P.O. Box No.) 5. G Separated (City) (State) (ZIP) Employment: G I am not employed G I am employed by (Employer's name) (Employer's Address) I have been employed by this employer since The name of my job is My income is $ 6. G Monthly G Weekly G Per hour Financial Status: A. Real Property American LegalNet, Inc. www.FormsWorkflow.com G I do not own any real property G I own the following real property: 1. Description: 2. Address: 3. Name of property owner(s): 4. Estimated value: $ 5. Total amount owed on property: $ 6. I receive $ Owed to: each year from this property. B. Other Property 1. Automobile: Brand Name Model Year 2. Registered owner's name: 3. Present value of car: $ Amount owed: $ Owed to: Monthly payment: $ C. Cash 1. I have $ Number of payments remaining: cash on hand. 2. I have $ in the following bank or credit union or savings association: D. Stocks, Bonds, Insurance Money, Veterans Benefits, Social Security, and Other Benefits G I have the following stocks, bonds, or other investments: G I receive $ from stocks, bonds, or other investments G I receive from insurance $ G I receive $ from the Veterans Administration G I receive $ from Social Security G I receive $ from -2American LegalNet, Inc. www.FormsWorkflow.com E. Debts and Obligations G I own my home. My monthly mortgage payment is $ G I rent my home. My monthly rent payment is $ G I do not owe any other debts. G I have the following debts $ Payable to $ Payable to $ Payable to $ Payable to $ Payable to $ Payable to $ Payable to $ Payable to The total of my monthly payments, including rent or mortgage, car payments, and all other debts is $ 7. Statement of Discrimination Claim. My discrimination claim is stated in my Complaint. 8. I tried diligently to hire a lawyer, with the following results: (Check all that apply) G I contacted the following private lawyers who specialize in labor law, employment discrimination law, or civil rights law, but they would not take my case because: LAWYER’ NAME & ADDRESS S REASON FOR REFUSING TO TAKE MY CASE -3American LegalNet, Inc. www.FormsWorkflow.com G I contacted the Legal Services Corporation (tel. 662. 234-2918), but they would not take my case because: G I contacted the Mississippi Bar Association Lawyer Referral Service (1-800 682-6423). The Service gave me the names of the lawyers listed below. I contacted the lawyers but they would not take my case because: LAWYER’ NAME & ADDRESS S REASON FOR REFUSING TO TAKE MY CASE 9. I have the following education (check highest level attained): G Did not graduate from high school, but completed the grade. -4American LegalNet, Inc. www.FormsWorkflow.com G GED G High school graduate G Attended college or community college G Specialty or technical school (Date attained: ). (Year graduated: ). (Total hours credit: ). (Field of study: ). Specialty degree or technical skill or certification: G College graduate G College post-graduate education College: Year: 10. I request that the court grant me leave under Title VII of the Civil Rights Act of 1964 to file my lawsuit without payment of fees or costs or giving security therefor and that the court appoint a lawyer for me as is allowed by law. Signature I declare or certify or verify or state under penalty of perjury that the foregoing is true and correct. Date signed: Signature -5American LegalNet, Inc. www.FormsWorkflow.com AO 440 (ND MISS 1/00) SUMMONS IN A CIVIL ACTION UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF MISSISSIPPI SUMMONS IN A CIVIL ACTION VS. CASE NUMBER TO (name and address of Defendant): YOU ARE HEREBY SUMMONED and required to serve upon (check one): G Plaintiff’s attorney, or G Plaintiff pro se whose name and address are: a written Answer to the Complaint which is herewith served upon you, within days after service of this Summons upon you, exclusive of the day of service. If you fail to do so, judgment by default will be taken against you for the relief demanded in the Complaint. You must also file a copy of your written Answer with the Clerk of this court within a reasonable time after serving your Answer upon the Defendant. DAVID CREWS, Clerk Date: By: Deputy Clerk American LegalNet, Inc. www.FormsWorkflow.com AO 440 (ND MISS 1/00) SUMMONS IN A CIVIL ACTION RETURN OF SERVICE Service of this Summons and Complaint was made by me* on this date: Server’ s Name (print): Server’ s Title: Check one box below to state method of service: Served Summons and Complaint upon Defendant personally at the following place: Left copies of Summons and Complaint at Defendant’ dwelling house or usual place of abode s with the following person of suitable age and discretion then residing therein: Returned unexecuted: Other (specify): STATEMENT OF SERVICE FEES Travel: $ Services: $ Total: $ DECLARATION OF SERVER I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and the Statement of Service Fees is true and correct. Date executed: Signature of Server Server’ Address s Server’ Telephone Number s *As to who may serve a Summons, see Rule 4, FEDERAL RULES OF CIVIL PROCEDURE -2American LegalNet, Inc. www.FormsWorkflow.com