UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI ____________________DIVISION ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ___________________________________ NAME OF THE PLAINTIFF - vs ___________________________________ ___________________________________ ___________________________________ ___________________________________ NAME OF THE DEFENDANT OR DEFENDANTS (Enter above the full name(s) of ALL defendant(s) in this lawsuit. Please attach additional sheets if necessary. Case No. JURY TRIAL DEMANDED YES___ NO___ 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 Disabilities Act, you must first obtain a right-to-sue letter from the Equal Employment Opportunity Commission. ____ American LegalNet, Inc. www.FormsWorkflow.com ____ Rehabilitation Act of 1973, as amended, 29 U.S.C. §§ 701, et seq., for employment discrimination on the basis of a disability by an employer which constitutes a program or activity receiving federal financial assistance. NOTE: In order to bring suit in federal district court under the Rehabilitation Act of 1973, you must first file charges with the appropriate Equal Employment Office representative or agency. ____ Other (Describe) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ PARTIES 2. Plaintiff's name: ____________________________________________________ Plaintiff's address: ___________________________________________________ Street address or P.O. Box ___________________________________________________ City/ County/ State/Zip Code ____________________________________________________ Area code and telephone number 3. Defendant's name: __________________________________________________ Defendant's address: ________________________________________________ Street address or P.O. Box ________________________________________________ City/County/State/ Zip Code ________________________________________________ Area code and telephone number NOTE: IF THERE ARE ADDITIONAL PLAINTIFFS OR DEFENDANTS, PLEASE PROVIDE THEIR NAMES, ADDRESSES AND TELEPHONE NUMBERS ON A SEPARATE SHEET OF PAPER. 2 American LegalNet, Inc. www.FormsWorkflow.com 4. If you are claiming that the discriminatory conduct occurred at a different location, please provide the following information: ________________________________________________________________________________ (Street Address) (City/County) (State) (Zip Code) 5. When did the discrimination occur? Please give the date or time period: _______________________________________________________________________________ ADMINISTRATIVE PROCEDURES 6. Did you file a charge of discrimination against the defendant(s) with the Missouri Commission on Human Rights? _____Yes _____ No 7. Did you file a charge of discrimination against the defendant(s) with the Equal Date filed: _____________________________ Employment Opportunity Commission or other federal agency? _____Yes _____No 8. Have you received a Notice of Right-to-Sue Letter? _____Yes _____ No Date filed: _____________________________ If yes, please attach a copy of the letter to this complaint. 9. 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 the Equal Employment Opportunity Commission. 3 American LegalNet, Inc. www.FormsWorkflow.com . 10. NATURE OF THE CASE 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 ____ other conduct (specify): _________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Did you complain about this same conduct in your charge of discrimination? _____Yes _____ No 4 American LegalNet, Inc. www.FormsWorkflow.com 11. I believe that I was discriminated against because of my (check all that apply): ____ race ____ religion ____ ____ ____ ____ national origin color gender disability ____ age (my birth date is: ____________) ____ other: _________________________________________________________ ______________________________________________________________________________ Did you state the same reason(s) in your charge of discrimination? _____Yes _____ No 12. State here, as briefly and clearly as possible, the essential facts of your claim. Describe specifically the conduct that you believe is discriminatory and describe how each defendant is involved in the conduct. Take time to organize your statement; you may use numbered paragraphs if you find it helpful. It is not necessary to make legal arguments, or to cite cases or statutes. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________