Discrimination Complaint

UNITED STATES DISTRICT COURT Revised 05/01 WDNYWESTERN DISTRICT OF NEW YORK Jury Trial Demanded: Yes____ No____ Name(s) of Plaintiff or Plaintiffs -vs- DISCRIMINATION COMPLAINT __________-CV- ___________ Name of Defendant or Defendants 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 fir st 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. 1. My address is: My telephone number is: <<<<<<<<<********>>>>>>>>>>>>> 22. 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: 4. I was first employed by the defendant on (date): 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): 2<<<<<<<<<********>>>>>>>>>>>>> 3 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 defendants 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 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. Failure to provide me with reasonable accommodations to the application process 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. Other actions (please describe) 3<<<<<<<<<********>>>>>>>>>>>>> 414. Defendants conduct is discriminatory with respect to which of the following (check all that apply): a. Race f. Sexual Harassment b. Color g. Age Date of birth c. Sex h. Disability d. Religion Are you incorrectly perceived as being disabled by your employer? e. National Origin yes no15. I believe that I was ______/was not _____ intentionally discriminated against by the defendant(s). 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 d