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Complaint (For Employment Discrimination) - New York
| Complaint (For Employment Discrimination) Form. This is a New York form and can be used in General Eastern District District Court Federal . |
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THE FILING FEE FOR A COMPLAINT IS $150.00 WHICHMAY BE PAID BY CASH, MONEY ORDER, BANK CERTIFIED CHECK OR PERSONAL CHECK. IF YOU CANNOT AFFORD TO PAY THE $150.00 FILING FEEYOU MAY ASK THE COURT TO WAIVE THE FILING FEE BY COMPLETING AND SUBMITTING A REQUEST TO PROCEED IN FORMA PAUPERIS DISCLOSING YOUR INCOME AND FINANCES. You must submit three copies of the complaint to the Pro Se Office: onemust contain your original signature in ink and two may be copies of thecomplaint. Important: any exhibits attached to the original complaint mustalso be attached to the copies of the complaint. You must keep a copy ofwhatever you submit to the Court for yourself * * * * *In some types of actions, you are entitled to a trial by jury. However, youlose your right to a jury trial if you do not ask for it early enough.If you want a jury trial, you must write JURY TRIAL DEMANDED onthe front page of your complaint to the right of the caption, above or belowthe word complaint. You can also demand a jury trial within 10 days ofservice of the defendants answer. See Rule 38(b) of the Federal Rules ofCivil Procedure. * * * * *rev. 07/02 <<<<<<<<<********>>>>>>>>>>>>> 2UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK COMPLAINTNAME OF PLAINTIFF(S) V. NAME OF DEFENDANT(S) This action is brought for discrimination in employment pursuant to (check only thosethat 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 a 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. 92-592, the Civil Rights Act of 1991, Pub. L. No. 102-166). NOTE: In order to bring a suit in federal district court under the Age Discrimination in Employment Act, you must first 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. -1- <<<<<<<<<********>>>>>>>>>>>>> 3 Jurisdiction is specifically conferred upon this United States District Court by the aformentioned 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. Plaintiff resides at: Street Address I I County State Zip Code Telephone Number 2. Defendant(s) resides at, or its business is located at: Street Address I I County City State Zip Code3. The address at which I sought employment or was employed by the defendant(s) is: Street Address I I County City State Zip Code -2- <<<<<<<<<********>>>>>>>>>>>>> 44. The discriminatory conduct of which I complain in this action includes (check only those that apply). Failure to hire. Termination of my employment. Failure to promote. Failure to accommodate my disability. Unequal terms and conditions of my employment. Retaliation Other acts (specify): NOTE: Only those grounds raised in the charge filed with the Equal Employment OpportunityCommission can be considered by the federal district court. 5. It is my best recollection that the alleged discriminatory acts occurred on: Date(s) 6. I believe that the defendant(s) (check one) is still committing these acts against me. is not still committing these acts against me. 7. Defendant(s) discriminated against me based on my: (check only those that apply and state the basis for discrimination, for example, what is your religion, if religious discrimination is alleged) race color gender/sex religion national origin age My date of birth is: Date disability NOTE: Only those grounds raised in the charge filed with the Equal Employment Opportunity Commission can be considered by the federal district court. -3- <<<<<<<<<********>>>>>>>>>>>>> 58. The facts of my case are as follows: (Attach additional sheets as necessary) Note: As additional support for your claim, you may attach to this complaint a copy of the charge filed with the Equal Employment Opportunity Commission, the New York State Division of Human Rights, or the New York City Commission on Human Rights. 9. It is my best recollection that I filed a charge with the New York State Division of Human Rights or the New York City Commission on Human Rights regarding defendants alleged discriminatory conduct on: . Date 10. It is my best recollection that I filed a charge with the Equal Employment Opportunity Commission regarding defendants alleged discriminatory conduct on: . Date -4- <<<<<<<<<********>>>>>>>>>>>>> 6Only litigants alleging age discrimination must answer Question #11. 11. Since filing my charge of age discrimination with the Equal Employment Opportunity Commission regarding defendants alleged discriminatory conduct (check one), 60 days or more have elapsed. less than 60 days have elapsed.12. 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 DateNOTE: Attach a copy of the Right to Sue Letter from the Equal Employment Opportunity Commission to this complaint. WHEREFORE, plaintiff prays that the Court grant such relief as may be appropriate,including injunctive orders, damages, costs, and attorneys fees. PLAINTIFFS SIGNATUREDated: Address Phone Number -5-
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