About This Form 1. Not Legal Advice. This form does not provide legal advice. No form substitutes for having or consulting a lawyer. If you are not a lawyer and are suing or have been sued, it is best to have or consult a lawyer if possible. 2. No Guarantee. Following the form does not guarantee that the pleading is legally or factually correct or sufficient. 3. No Guidance on Timing or Parties. The form does not give any guidance on when certain kinds of pleadings or claims or defenses have to be raised, or who has to be sued. Some pleadings, claims, or defenses have to be raised at a certain point in the case or within a certain period of time. And there are limits on who can be named as a party in a case and when they have to be added. Lawyers and people representing themselves must know the Federal Rules of Civil Procedure and the caselaw setting out these and other requirements. The current Federal Rules of Civil Procedure are available, for free, at www.uscourts.gov. 4. Privacy Requirements. Federal Rule of Civil Procedure 5.2 addresses the privacy and security concerns over public access to electronic court files. Under this rule, papers filed with the court should not contain anyone222s full social-security number or full birth date; the name of a person known to be a minor; or a complete financial-account number. A filing may include only the last four digits of a social-security number and taxpayer identification number; the year of someone222s birth; a minor222s initials; and the last four digits of a financial-account number. 5. Except as noted in this form, plaintiff need not send exhibits, affidavits, witness statements, or any other materials to the Clerk222s Office with this complaint. 6. In order for your complaint to be filed, it must be accompanied by the filing fee or an application to proceed in forma pauperis. American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF MISSOURI DIVISION Complaint for Employment Discrimination (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 223see attached224 in the space and attach an additional page with the full list of names.) -against- Case No. (to be filled in by the Clerk222 s Office) (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 223see attached224 in the space and attach an additional page with the full list of names.) REQUEST FOR TRIAL BY JURY Plaintiff requests trial by jury. Yes No American LegalNet, Inc. www.FormsWorkFlow.com 2 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 person222s 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 American LegalNet, Inc. www.FormsWorkFlow.com 3 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 II. Cause of Action 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. 247247 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. 247247 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. 247247 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.) American LegalNet, Inc. www.FormsWorkFlow.com 4 Other federal law (specify the federal law): Missouri Human Rights Act, Missouri Revised Statute 247 213.055 Other state law (specify, if known): Relevant city or county law (specify, if known): III. Administrative Procedures A. Did you file a charge of discrimination against Defendant(s) with the Equal Employment Opportunity Commission or other federal agency? Yes Date filed: No Attach copy of the charge to this Complaint B. Have you received a Notice of Right-to-Sue Letter from the Equal Employment Opportunity Commission? Yes No If yes, please attach a copy of the letter to this Complaint. C. Did you file a charge of discrimination against Defendant(s) with the Missouri Commission on Human Rights? Yes Date filed: No Attach copy of the charge to this Complaint D. Have you received a Notice of Right-to-Sue Letter from the Missouri Human Rights Commission? Yes No If yes, please attach a copy of the letter to this Complaint. American LegalNet, Inc. www.FormsWorkFlow.com 5 E. 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 IV. Statement of Claim 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. Harassment/Hostile Work Environment 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 the following date(s): C. I believe that defendant(s) (check one): is/are still committing these acts against me. is/are not still committing these acts against me. American LegalNet, Inc. www.FormsWorkFlow.com 6 D. Defendant(s) discriminated against me based on my (check all that apply and explain): race color gender/sex religion national origin age. My year of birth is . (Give your year of birth only if you are asserting a claim of age discrimination.) disability or perceived disability (specify disability) E. Write a short and plain statement of FACTS that support your claim. Do not make legal arguments. You must include the following information: 225 What happened to you? 225 What injuries did you suffer? 225 Who was involved in what happened to you? 225 How were the defendants involved in what happened to you? 225 Where did the events you have described take place? 225 When did the events you have described take place? 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. American LegalNet, Inc. www.FormsWorkFlow.com 7 V. Relief As relief from the allegations of discrimination as stated above, Plaintiff prays that the court grant the following relief to Plaintiff: (check any and all that apply) Defendant be directed to employ Plaintiff Defendant be directed to re-employ Plaintiff Defendant be directed to promote Plaintiff Defendant be directed