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Employee Discrimination Complaint Package - California
| Employee Discrimination Complaint Package Form. This is a California form and can be used in General USDC Northern Federal . |
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UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 I. HOW TO FILE AN EMPLOYMENT DISCRIMINATION COMPLAINT: INSTRUCTIONS FOR PERSONS WITHOUT AN ATTORNEY This packet includes each of the following forms: 1. 2. 3. How to File an Employment Discrimination Complaint (Intake 1); Employment Discrimination Complaint (Intake 2); Application to Proceed In Forma Pauperis (Intake 3); GENERAL INSTRUCTIONS A. Three completed copies of each applicable form should be sent to the Court. Upon filing, the Clerk will return to you a file stamped copy of each document. If the documents submitted by you are not complete, you will be advised. When you mail in the forms, you should keep one set for your records. B. All blanks must be filled in. If an entry does not apply to you, write "not applicable" in the provided space. C. Effective February 7, 2005, the filing fee for a complaint is $250.00. If you are financially unable to pay that fee, you must complete the Application to Proceed In Forma Pauperis (Intake 3). If you are able to pay the $250.00 filing fee, you need not complete the Application to Proceed In Forma Pauperis. However, you must prepare a summons, have it issued by the Clerk's Office and make arrangements with a private process server to have your summons and complaint served upon the defendant. D. Your complaint must be filed within the time specified by your Notice-Of-RightTo-Sue letter. E. If you contact the Court about your case, you must use the name and number of the case: for instance. Jones v. Acme Construction, C02-0123ABC. This number will be stamped on the copies of your documents returned by the Clerk when your case is filed. The letters at the end of the number are the initials of the judge to whom your case has been randomly assigned. These letters are part of the case number and must be used by you if you inquire about your case. F. You must notify the Clerk promptly if your mailing address changes. If the Court is unable to contact you, your case may be dismissed for lack of prosecution. G. Before mailing your forms to the Court, you should remove these instructions and keep for reference. H. If you are filing a complaint against a Federal Agency, you should fill out all parts of the forms that apply to you and add any additional information that is appropriate. I. If you are a minor, include only your initials on all documents where your name is requested. DO NOT INCLUDE YOUR NAME. II. EMPLOYMENT DISCRIMINATION COMPLAINT (Intake 2) A. Insert the name of the employer(s) against whom you are complaining in the Form-Intake 1 (Rev. 2/05) American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 heading above the word "Defendant(s)." If you are complaining against a federal agency, department or unit, insert the title of the head of that agency, department or unit above the word "Defendant(s)." (For example, if you are complaining against the U.S. Postal Service, insert "Postmaster General;" if you are complaining against the U.S. Navy, insert "Secretary of the Navy.") Write your name above the word "Plaintiff." B. C. Paragraphs 1 and 2 - Be sure to provide full and accurate addresses. Paragraph 9 - Be sure to attach a copy of your Notice-Of-Right-To-Sue letter. THE COMPLAINT MUST BE FILED WITHIN THE TIME SPECIFIED IN YOUR NOTICE-OF-RIGHT-TO-SUE LETTER III. APPLICATION TO PROCEED IN FORMA PAUPERIS (Intake 3) A. This form should be used ONLY if you are financially unable to pay the $250.00 filing fee. Each complaint must be accompanied with either a $250.00 payment or a completed Application to Proceed In Forma Pauperis. B. All blanks must be filled in. If an entry does not apply to you, write "not applicable" in the provided space. When the forms are completed, bring them or mail them to: Clerk, United States District Court 450 Golden Gate Avenue P.O. Box 36060 San Francisco, CA 94102 Form-Intake 1 (Rev. 2/05) -2American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 3. 2. 1. Plaintiff resides at: Address City, State & Zip Code Phone Defendant is located at: Address City, State & Zip Code This action is brought pursuant to Title VII of the Civil Rights Act of 1964 for employvs. UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA ) ) Plaintiff, ) ) ) ) ) ) Defendant(s). ) ) ) CASE NO. EMPLOYMENT DISCRIMINATION COMPLAINT ment discrimination. Jurisdiction is conferred on this Court by 42 U.S.C. Section 2000e-5. Equitable and other relief is sought under 42 U.S.C. Section 2000e-5(g). 4. The acts complained of in this suit concern: a. b. Failure to employ me. Termination of my employment. -1American LegalNet, Inc. www.USCourtForms.com Form-Intake 2 (Rev. 4/05) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 8. 7. 6. 5. c. d. Failure to promote me. Other acts as specified below. Defendant's conduct is discriminatory with respect to the following: a. b. c. d. e. My race or color. My religion. My sex. My national origin. Other as specified below. The basic facts surrounding my claim of discrimination are: The alleged discrimination occurred on or about (DATE) . I filed charges with the Federal Equal Employment Opportunity Commission (or the California Department of Fair Employment and Housing) regarding defendant's alleged Form-Intake 2 (Rev. 4/05) -2American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 discriminatory conduct on or about (DATE) 9. . The Equal Employment Opportunity Commission issued a Notice-of-Right-to-Sue letter . (DATE) (copy attached), which was received by me on or about 10. Plaintiff hereby demands a jury for all claims for which a jury is permitted: Yes No 11. WHEREFORE, plaintiff prays that the Court grant such relief as may be appropriate, including injunctive orders, damages, costs, and attorney fees. DATED: SIGNATURE OF PLAINTIFF (PLEASE NOTE: NOTARIZATION IS NOT REQUIRED.) PLAINTIFF'S NAME (Printed or Typed) Form-Intake 2 (Rev. 4/05) -3American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 If the answer is "no," state the date of last employment and the amount of the gross and net salary 1. I, , declare, under penalty of perjury that I am the plaintiff Defendant. vs. Plaintiff
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