COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : FORMAL COMPLAINT UNDER EEO/EDR PLAN Calendar No. : JUDICIAL SUBPOENA Filed Under the Procedures ofPlaintiff(s) the District of Nebraska Equal Employment -againstOpportunity and Employment Dispute Resolution: Plan (“District of Nebraska EEO/DER Plan”). : Prior to completing this form, please refer to the District of Nebraska EEO/EDR Plan. : Please complete this form legibly. Defendant(s) : . . 1.. . . . . .Full. Name of . . . . . . Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Person . . . . . Complaint 2. Mailing Address THE PEOPLE OF THE STATE OF NEW YORK 3. TO Home Phone ( ) Work Phone ( ) 4. If you are a court employee, state the following: Court Unit in which employed Job GREETINGS:Title 5. Name and address of the that all business and excuses being laid aside, is filed each of you attend WE COMMAND YOU, Employing Office against which this complaintyou and(under the terms of before the District of Nebraska EEO/EDR Plan, all complaints must be filed against an “Employing Office,” , the Honorable at the Court located at County of not an individual): 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 ______________________________________________________________________________ 6. Identify the Chapter(s) of the District of Nebraska EEO/EDR Plan under which your complaint is Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to being filed. 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. G Chapter II - Equal Employment Opportunity & Anti-Discrimination Rights G Race Witness,G Honorable , one of the Justices of the Color Court in County, day of , 20 G Religion G Gender/Sex (includes sexual harassment) G National Origin G Age (Attorney must sign above and type name below) G Disability G Chapter III - Family and Medical Leave Rights Attorney(s) for G Chapter IV - Worker Adjustment and Retraining Notification Rights G Chapter V - Employment and Reemployment Rights of Members of the Office and P.O. Address Uniformed Services G Chapter VI - Occupational Safety and Health Protections Telephone No.: Facsimile No.: E-Mail Address: 1 Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : G 7. 8. Calendar No. : JUDICIAL SUBPOENA Chapter VII - Polygraph Tests Plaintiff(s) Date(s) of alleged violation: -againstDate on which counseling was requested: Date on which counseling was completed: Date on which mediation was requested: Date on which mediation was concluded: : : : Defendant(s) : . .9. . . . . . Name . . .person who. served .as.Counselor . . .this. matter:. . . . . . . . of . . . . . . . . . . . . . . . . . . . . . . on . . . . . . . 10. Name of person who served as Mediator on this matter: THE PEOPLE OF THE STATE OF NEW YORK giving rise to your complaint. Explain in what way you 11. Please summarize the actions or occurrences believe your rights under the District of Nebraska EEO/EDR Plan were violated. Identify all persons TO who participated in this matter or who can provide relevant information concerning your complaint. (If there is insufficient space below, you may attach additional pages.) GREETINGS: 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) [Please attach a copy of any documents that relate to your complaint, such for an application form, resume, Attorney(s) as letters, notices of discipline or termination, etc.] 12. What corrective action do you seek from your complaint? Office and P.O. Address 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 13. Index No. Calendar No. : Do you have an attorney or any other person who represents you in this matter? JUDICIAL SUBPOENA Plaintiff(s) G Yes G No -against: If yes, please provide the following information concerning that person: : Name : Address Defendant(s) : . . . . . . . . Work. Phone .( . . . . ) . . . . . . . . . . . . . . . . Fax .(. . . . ). . . . . . .... ..... . ... THE PEOPLE OF THE STATE OF NEW YORK in this complaint is true and correct to the best of my I swear or affirm that the information provided knowledge. TO GREETINGS: Signature Date 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 3 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com