UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK Revised 07/07 WDNY Jury Trial Demanded: Yes____ No____ Name(s) of Plaintiff or Plaintiffs -vs- DISCRIMINATION COMPLAINT __________-CV- ___________ Name of Defendant or Defendants You should attach a copy of your original Equal Employment Opportunity Commission (EEOC) complaint, a copy of the Equal Employment Opportunity Commission decision, AND a copy of the "Right to Sue" letter you received from the EEOC to this complaint. Failure to do so may delay your case. 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. This action is brought for discrimination in employment pursuant to (check only those that apply): Title VII of the Civil Rights Act of 1964, as codified, 42 U.S.C. §§ 2000e to 2000e-17 (amended in 1972, 1978 and by the Civil Rights Act of 1991, Pub.L.No. 102-166) (race, color, gender, religion, 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 codified, 29 U.S.C. §§ 621-634 (amended in 1984, 1990, and by the Age Discrimination in Employment Amendments of 1986, Pub.L.No. 99-592, the Civil Rights Act of 1991, Pub.L.No. 102-166). 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. Americans with Disabilities Act of 1990, as codified, 42 U.S.C. §§ 12112-12117 (amended by the Civil Rights Act of 1991, Pub.L.No. 102-166). NOTE: In order to bring suit in federal district court under the Americans with Disabilities Act, you must first obtain a right to sue letter from the Equal Employment Opportunity Commission. JURISDICTION is specifically conferred upon this United States District Court by the aforementioned statutes, as well as 28 U.S.C. §§ 1331, 1343. Jurisdiction may also be appropriate under 42 U.S.C. §§ 1981, 1983 and 1985(3), as amended by the Civil Rights Act of 1991, Pub.L.No. 102-166, and any related claims under New York law. American LegalNet, Inc. www.FormsWorkflow.com In addition to the federal claims indicated above, you may wish to include New York State claims, pursuant to 28 U.S.C. § 1367(a). ______ New York State Human Rights Law, N.Y. Exec. Law §§ 290 to 297 (age, race, creed, color, national origin, sexual orientation, military status, sex, disability, predisposing genetic characteristics, marital status). PARTIES 1. My address is: My telephone number is: 2. The name of the employer(s), labor organization, employment agency, apprenticeship committee, state or local government agency who I believe discriminated against me is/are as follows: Name: Number of employees: Address: 3. (If different than the above), the name and/or the address of the defendant with whom I sought employment, was employed by, received my paycheck from or whom I believed also controlled the terms and conditions under which I were paid or worked. (For example, you worked for a subsidiary of a larger company and that larger company set personnel policies and issued you your paycheck). Name: Address: CLAIMS 4. I was first employed by the defendant on (date): 2 American LegalNet, Inc. www.FormsWorkflow.com 5. As nearly as possible, the date when the first alleged discriminatory act occurred is: 6. As nearly as possible, the date(s) when subsequent acts of discrimination occurred (if any did): 7. I believe that the defendant(s) a. Are still committing these acts against me. b. Are not still committing these acts against me. (Complete this next item only if you checked “b” above) The last discriminatory act against me occurred on (date) 8. (Complete this section only if you filed a complaint with the New York State Division of Human Rights) The date when I filed a complaint with the New York State Division of Human Rights is ________________________________________________________________________ _ (estimate the date, if necessary) I filed that complaint in (identify the city and state): The Complaint Number was: 9. The New York State Human Rights Commission did ___________ /did not ___________ issue a decision. (NOTE: If it did issue a decision, you must attach one copy of the decision to each copy of the complaint; failure to do so will delay the initiation of your case.) 10. The date (if necessary, estimate the date as accurately as possible) I filed charges with the Equal Employment Opportunity Commission (EEOC) regarding defendant's alleged discriminatory conduct is: 11. The Equal Employment Opportunity Commission did ____________ /did not ____________ issue a decision. (NOTE: If it did issue a decision, you must attach one copy of the decision to each copy of the complaint; failure to do so will delay the initiation of your case.) 12. The Equal Employment Opportunity Commission issued the attached Notice of Right to Sue letter which I received on: . (NOTE: If it 3 American LegalNet, Inc. www.FormsWorkflow.com did issue a Right to Sue letter, you must attach one copy of the decision to each copy of the complaint; failure to do so will delay the initiation of your case.) 13. I am complaining in this action of the following types of actions by the defendants: a. b. Failure to employ me c. Termination of my employment d. Failure to promote me e. Failure to provide me with reasonable accommodations so I can perform the essential functions of my job f. Harassment on the basis of my sex g. Harassment on the basis of unequal terms and conditions of my employment h. Retaliation because I complained about discrimination or harassment directed toward me i. Retaliation because I complained about discrimination or harassment directed toward others j. 14. Failure to provide me with reasonable accommodations to the application process Other actions (please describe) Defendant's conduct is discriminatory with respect to which of the following (check all that apply): a. Race f. Sexual Harassment b. Color g. Age c. Sex d. Religion e. National Origin Date of birth 15. h. Disability Are you incorrectly perceived as being disabled by your employer? yes no I believe that I was ______/was not _____ intentionally discriminated against by the defendant(s). 4 American LegalNet, Inc. www.FormsWorkflow.com 16. I believe that the defendant(s) is/are _____ is not/are not _____ still committing these acts against me. (If you answer is that the acts are not still being committed, state when: ____________________ and why the defendant(s) stopped committing these acts against you: 17. A copy of the charge to the Equal Employment Opportunity Commission is attached to this complaint and is submitted as a brief statement of the facts of my claim. (NOTE: You must attach a copy of the original complaint you filed with the Equal Employment Opportunity Commission and a copy of the Equal Employment Opportunity Commission affidavit to this complaint; failure to do so will delay initiation of your case.) 18. The Equal Employment Opportunity Commission (check one): has not issued a Right to sue letter has issued a Right to sue letter, which I received on 19. State here as briefly as possible the facts of your case. Describe how each defendant is involved, including dates and places. Do not give any legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate paragraph. (Use as much space as you need. Attach extra sheets if necessary.) FOR LITIGANTS ALLEGING AGE DISCRIMINATION 20. Since filing my charge of age discrimination with the Equal Employment Opportunity Commission regarding defendant's alleged discriminatory conduct 60 days or more have elapsed less than 60 days have elapsed FOR LITIGANTS ALLEGING AN AMERICANS WITH DISABILITIES ACT CLAIM 21. I first disclosed my disability to my employer (or my employer first became aware of my disability on 5 American LegalNet, Inc. www.FormsWorkflow.com 22. The date on which I first asked my employer for reasonable accommodation of my disability is 23. The reasonable accommodations for my disability (if any) that my employer provided to me are: 24. The reasonable accommodation provided to me by my employer were _____/were not ______ effective. WHEREFORE, I respectfully request this Court to grant me such relief as may be appropriate, including injunctive orders, damages, costs and attorney's fees. Dated: Plaintiff's Signature 6 American LegalNet, Inc. www.FormsWorkflow.com