ATTACHMENT 2 - EEOC Complaint Form United States District Court for the Western District of Texas Division (Name of plaintiff or plaintiffs) Civil Action Number: v. (Case Number to be supplied by the Intake Clerk) (Name of defendant or defendants) COMPLAINT 1. This action is brought by following selected jurisdiction: , Plaintiff, pursuant to the (Please select the applicable jurisdiction) [] Title VII of the Civil Rights Act of 1964 (42 USC �� 2000e et seq.) Employment Discrimination on the basis of race, color, sex (gender, pregnancy and sexual harassment), religion or national origin. The Age Discrimination in Employment Act (29 USC �� 621 et seq.) (ADEA). The Americans With Disabilities Act (42 USC �� 12102 et seq.) (ADA). The Equal Pay Act (29 USC � 206(d)) (EPA). The Rehabilitation Act of 1973 (29 USC �791 et seq.) (Applicable to federal employees only). [] [] [] [] 25 American LegalNet, Inc. www.USCourtForms.com 2. Defendant is located at (city), (Defendant's name) lives at, or its business (street address), (state), (zip). 3a. Plaintiff sought employment from the defendant or was employed by the defendant at (street address), (city), (state), (zip). At all relevant times of claim of discrimination, Defendant employed (#) employees. If defendant is a union, at all relevant times of claim of discrimination, Defendant had (#) members. Defendant discriminated against plaintiff in the manner indicated in paragraph 8 of this complaint on or about (month) (day) (year). If incidents of discrimination occurred more than one day, please indicate the beginning and ending dates of such acts: . 3b. 4. 5. Plaintiff filed charges against the defendant with the Equal Employment Opportunity Commission (E.E.O.C.) charging defendant with the acts of discrimination indicated in paragraph 7 of this complaint on or about (month) (day) (year). (Not applicable to federal civil service employees). The E.E.O.C. issued a Notice of Right to Sue which was received by plaintiff on (month) (day) (year). (Not applicable to ADEA and EPA claims or federal civil service employees). PLEASE ATTACH A COPY OF YOUR NOTICE OF RIGHT TO SUE AND THE ENVELOPE IN WHICH IT WAS RECEIVED TO THIS COMPLAINT. 6a. VERY IMPORTANT NOTE: 6b. Please indicate below if the E.E.O.C issued a Determination in your case: [ ] Yes [ ] No VERY IMPORTANT NOTE: IF YOU CHECKED "YES", PLEASE ATTACH A COPY OF THE E.E.O.C.'S DETERMINATION TO THIS COMPLAINT. 26 American LegalNet, Inc. www.USCourtForms.com 7. Because of plaintiff's: (Please select the applicable allegation(s)) [] [] [] Race (If applicable, state race) Color (If applicable, state color) Sex (gender, pregnancy or sexual harassment) (If applicable, state sex and claim) Religion (If applicable, state religion) National Origin (If applicable, state national origin) Age (If applicable, state date of birth) Disability (If applicable, state disability) Prior complaint of discrimination or opposition to acts of discrimination. (Retaliation) (If applicable, explain events of retaliation) . The defendant: (please select all that apply) [] [] [] [] [] failed to employ plaintiff. terminated plaintiff's employment. failed to promote plaintiff. harassed plaintiff. other (specify) [] [] [] [] [] . 27 American LegalNet, Inc. www.USCourtForms.com 8a. State specifically the circumstances under which defendant, its agent, or employees discriminated against plaintiff PERSONALLY: INCLUDE SPECIFIC DATES, SPECIFIC EVENTS, AND ANY SPECIFIC COMMENTS MADE BY DEFENDANT PERTAINING TO THE DISCRIMINATION CLAIM ALLEGED ABOVE. VERY IMPORTANT NOTE: . 8b. List any witnesses who would testify for plaintiff to support plaintiff's allegations and the substance of their testimony: . 8c. List any documentation that would support plaintiff's allegations and explain what the documents will prove: . 9. The above acts or omissions set forth in paragraphs 7 and 8 are: [] [] still being committed by defendant. no longer being committed by defendant. 10. Plaintiff should attach to this complaint a copy of the charge filed with the Equal Employment Opportunity Commission. This charge is submitted as a brief statement of the facts supporting this complaint. 28 American LegalNet, Inc. www.USCourtForms.com WHEREFORE, plaintiff prays that the Court grant the following relief to the plaintiff: [] [] [] [] Defendant be directed to employ plaintiff. Defendant be directed to re-employ plaintiff. Defendant be directed to promote plaintiff. Defendant be directed to and that the Court grant such other relief as may be appropriate, including injunctive orders, damages, costs and attorney's fees. I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Date Signature of Plaintiff Address of Plaintiff City State Zip Code Telephone Number(s) 29 American LegalNet, Inc. www.USCourtForms.com