Complaint Under Section 706(f) Of Civil Rights Act Of 1964

(Rev. 12/6/12) INSTRUCTIONS FOR FILING A LAWSUIT UNDER THE CIVIL RIGHTS ACT OF 1964 (EEOC 42:2000) This is in response to your inquiry about a lawsuit you may wish to bring under Title VII of the Civil Rights Act of 1964. Under this law the Court is, upon application by a complainant, permitted to appoint an attorney for the applicant and to allow commencement of the action without prepayment of fees, costs or security. Any such application is, at the direction of this Court, to be in writing and to be filed with this office. Forms for these applications are available upon request or on our website (www.lawd.uscourts.gov). You are cautioned that any lawsuit under Title VII to be brought by you or on your behalf must be filed within 90 days after receipt by you of the EEOC's "right-to-sue" notice. A delay on your part in filing an application for appointment of an attorney or waiver of prepayment of fees may result in loss of rights under Title VII. The clerk will automatically refer any motions you submit in connection with your complaint to the appropriate judge or magistrate judge, and will promptly send you copies of any orders signed in response to your motions. If your case is allowed to be filed, the order will reflect a Civil Action number which you should provide with all future inquiries and pleadings. If you need additional copies of this application form or further information, please advise this office. Very truly yours, TONY R. MOORE Clerk of Court 300 Fannin Street, Suite 1167 Shreveport, LA 71101-1167 318-676-4273 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 12/6/12) UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA DIVISION Civil Action No. Plaintiff VS. Judge Magistrate Judge Defendant COMPLAINT UNDER SECTION 706 (f) OF THE CIVIL RIGHTS ACT OF 1964 A. Describe in your own words the employment practices about which you are complaining, identifying the persons, firms, companies, unions, agencies or bodies you say have engaged in such practices. Attach an additional sheet, if necessary. B. Have you filed with the Equal Employment Opportunity Commission (EEOC) a charge Yes No relating to such practices? C. Have you received from the EEOC a letter notifying you of your "right-to-sue" respecting Yes No such charges? If "Yes," attach a copy of such letter and notice, and state when you received same. Date received: Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 12/6/12) D. Have you received from the EEOC a copy of its determination with regard to your charges? Yes No If "Yes," attach a copy of such determination. Also, if you disagree with any of the EEOC's findings or conclusions, state why: E. Give any other information you desire to disclose which supports your claim of discriminatory employment practices. F. Under penalty of perjury, I declare that the information given in this complaint is true and correct. Date: (Signature) (Street Address or P.O. Box) (Witness) (City, State, Zip Code) - (Witness) (Area Code) (Telephone Number) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com