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Complaint For Employment Discrimination Based Upon Age Form. This is a New York form and can be use in District Court Federal.
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Tags: Complaint For Employment Discrimination Based Upon Age, New York Federal, District Court
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF NEW YORK
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Plaintiff(s)
vs.
Defendant(s)
Plaintiff(s) demand(s) a trial by: ____ JURY
Civil Case No.:
COMPLAINT FOR
EMPLOYMENT
DISCRIMINATION
BASED UPON AGE
_____ COURT
(Select only one).
Plaintiff(s) in the above-captioned action, allege(s) as follows:
JURISDICTION
1.
Jurisdiction is conferred on this court pursuant to 29 U.S.C. §§ 626(c)(1). If the plaintiff is
a federal employee, jurisdiction is conferred on this court pursuant to 29 U.S.C. § 633a(c).
PARTIES
2. a.
Plaintiff:
Address:
b. Plaintiff:
Address:
Additional Plaintiffs may be added on a separate sheet of paper.
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3.
a.
Defendant:
Official Position:
Address:
b.
Defendant:
Official Position:
Address:
Additional Defendants may be added on a separate sheet of paper.
4.
This action is brought pursuant to the Age Discrimination in Employment Act of 1967, 29
U.S.C. §§ 621-634(b), as amended, for employment discrimination based on age.
5.
Venue is invoked pursuant to 28 U.S.C. § 1391.
6.
The conduct complained of in this action involves:
(A)
Failure to employ
(B)
Termination of employment
(C)
Failure to promote
(D)
Unequal terms and conditions of employment
(E)
Reduction in wages
(F)
Retaliation
(G)
Other acts as specified below:
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FACTS
7.
Set forth the facts of your case which substantiate your claim of discrimination. List the
events in the order they happened, naming defendants involved, dates and places.
Note: Each fact should be stated in a separate paragraph; paragraphs should be
numbered sequentially.
You must include allegations of wrongful conduct as to EACH and EVERY
defendant in your complaint.
The facts surrounding my claim of discrimination are:
8.
My date of birth is:
(b)
9.
(a)
,
My age at the time of the alleged discriminatory act was:
.
.
I filed charges with the New York State Division on Human Rights or the New York City
Commission on Human Rights regarding the alleged discriminatory acts on or about:
, 20
(Date)
10.
I filed a Notice of Intent with the Equal Employment Opportunity Commission on or about:
, 20
(Date)
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11.
The Equal Employment Opportunity Commission issued a Notice-of-Right-to-Sue letter
(copy attached) which was received by me on or about:
, 20
(Date)
12.
The plaintiff is an employee within the meaning of 29 U.S.C. § 630(f).
13.
The plaintiff is within the age limits as prescribed by 29 U.S.C. § 631(a).
14.
The defendant(s) is (are) an employer, employment agency, or labor organization within the
meaning of 29 U.S.C. § 630(b) (c) and (d).
15.
The defendant(s) is (are) engaged in commerce within the meaning of 29 U.S.C. § 630(h).
16.
In accordance with 29 U.S.C. § 626(d) and § 633(b), more than sixty (60) days have
elapsed since filing a charge alleging unlawful discrimination with the New York State
Division of Human Rights, the New York City Commission on Human Rights or the Equal
Employment Opportunity Commission.
17.
If plaintiff is a federal employee and has not filed a complaint with the Equal Employment
Opportunity Commission, in accordance with 29 U.S.C. § 633a(d) a thirty (30) day Notice
of Intent to File this action must been given to the Equal Employment Opportunity
Commission before an action may be brought in this Court.
18.
PRAYER FOR RELIEF
WHEREFORE, plaintiff(s) request(s) that this Court grant the following relief:
I declare under penalty of perjury that the foregoing is true and correct.
DATED:
Signature of Plaintiff(s)
(all Plaintiffs must sign)
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