Employment Discrimination Complaint

UNITED STATES DISTRICT COURT DISTRICT OF MINNESOTA Plaintiff(s), vs. Case No. ______________ (To be assigned by Clerk of District Court) DEMAND FOR JURY TRIAL YES ___ NO ___ Defendant(s). (Enter the full name(s) of ALL plaintiffs and defendants in this lawsuit. Please attach additional sheets if necessary.) EMPLOYMENT DISCRIMINATION COMPLAINT PARTIES 1. List your name, address and telephone number. Do the same for any additional plaintiffs. a. Plaintiff Name Street Address County, City State & Zip Code Telephone Number 2. List all defendants. You should state the full name of the defendant, even if that defendant is a government agency, an organization, a corporation, or an individual. Include the address American LegalNet, Inc. www.FormsWorkFlow.com where each defendant may be served. Make sure that the defendant(s) listed below are identical to those contained in the above caption. a. Defendant No. 1 Name Street Address County, City State & Zip Code b. Defendant No. 2 Name Street Address County, City State & Zip Code NOTE: IF THERE ARE ADDITIONAL PLAINTIFFS OR DEFENDANTS, PLEASE PROVIDE THEIR NAMES AND ADDRESSES ON A SEPARATE SHEET OF PAPER. Check here if additional sheets of paper are attached: Please label the attached sheets of paper to correspond to the appropriate numbered paragraph above (e.g., Additional Defendants 2.c., 2.d., etc.) JURISDICTION The Court has jurisdiction over this action under 28 U.S.C. § 1331. 3. This employment discrimination lawsuit is based on (check only those that apply): a. ___ Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. §§ 2000e, et. seq., for employment discrimination on the basis of race, color, religion, gender, or 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 (EEOC). b. ___ Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. §§ 621, et. seq., for employment discrimination on the basis of age (age 40 or older). NOTE: In 2 American LegalNet, Inc. www.FormsWorkFlow.com 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 (EEOC). c. ___ Americans with Disabilities Act of 1990, as amended, 42 U.S.C. §§ 12101, et. seq., for employment discrimination on the basis of disability. NOTE: In order to bring suit in federal court under the Americans with Disabilities Act, you must first obtain a rightto-sue letter from the Equal Employment Opportunity Commission (EEOC). d. __ Rehabilitation Act of 1973, as amended, 29 U.S.C. §§ 701, et. seq., for employment discrimination on the basis of a disability by an employer which constitutes a program or activity receiving federal financial assistance. NOTE: In order to bring suit in federal district court under the Rehabilitation Act of 1973, you must first file charges with the appropriate Equal Employment Office (EEO) representative or agency. e. __ Other (Please describe.) 4. If you are claiming that the discriminatory conduct occurred at a location other than the defendant's address above, please provide the following information on where the conduct occurred: (Street Address) (City/County) (State) (Zip Code) 5. When did the discrimination occur? Please give the date or time period: ADMINISTRATIVE PROCEDURES 6. Did you file a charge of discrimination against the defendant(s) with the Equal Employment Opportunity Commission or other federal agency? a. ___ Yes b. ___ No 7. Have you received a Notice of Right-to-Sue Letter? Date filed: _________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com a. ____ Yes b. ____ No If yes, please attach a copy of the letter to this complaint. NATURE OF THE CASE 8. The conduct complained of in this law suit involves (check only those that apply): a. ___ Failure to hire me b. ___ Termination of my employment c. ___ Failure to promote me d. ___ Failure to accommodate my disability e. ___ Terms and conditions of employment differ from those of similar employees f. ___ Retaliation g. ___ Harassment h. ___ Other conduct (please specify): i. Did you complain about this same conduct in the charge of discrimination, referred to in number 6 above? ___ Yes ___ No 9. I believe that I was discriminated against because of my (check all that apply): a. ___ Race b. ___ Religion c. ___ National origin 4 American LegalNet, Inc. www.FormsWorkFlow.com d. ___ Color e. ___ Gender f. ___ Disability g. ___ Age (my birth year is:________) h. ___ Other (please specify): i. Did you state the same reason(s) in the charge of discrimination, referred to in number 6 above? ___ Yes ___No Describe in the space provided below the basic facts of your claim. The description of facts should include a specific explanation of the conduct that you believe is discriminatory and describe how each defendant is involved in the conduct (i.e. how, where, and when). Each paragraph must be numbered separately, beginning with number 10. Please write each allegation of discrimination in a separately numbered paragraph. 10. 5 American LegalNet, Inc. www.FormsWorkFlow.com Attach additional sheets of paper as necessary. Check here if additional sheets of paper are attached: Please label the attached sheets of paper as Additional Facts and continue to number the paragraphs consecutively. REQUEST FOR RELIEF State briefly and exactly what you want the Court to do for you and the amount of monetary compensation, if any, you are seeking. Date: ______________________________________ Signature of Plaintiff Mailing Address Telephone Number Note: All plaintiffs named in the caption of the complaint must date and sign the complaint and provide his/her mailing address and telephone number. Attach additional sheets of paper as necessary. 6 American LegalNet, Inc. www.FormsWorkFlow.com