Kansas > Federal > District Court
Civil Complaint Pursuant To Title VII Of Civil Rights Act Of 1964 - Kansas
| Civil Complaint Pursuant To Title VII Of Civil Rights Act Of 1964 Form. This is a Kansas form and can be used in District Court Federal . |
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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS ) ) ) ) ) (Enter above the full name of the Plaintiff(s) ) ) vs. ) ) (1) ) Name ) ) Case Number: ) Street and number ) ) ) City State Zip Code ) ) (Enter above the full name and address of the Defendant in this action - list the name and address of any additional defendants on the back side of this sheet). CIVIL COMPL AINT P URSUANT TO TITLE VII OF THE CIVIL RIGHTS ACT OF 1964 OR 29 U.S.C. 621-634(b) (Age Discrimination in Employment Act) or 42 U.S.C. 12111 et seq. (Americans With Disabilities Act) Mark the statute that you are filing this complaint under: _____ Title VII of the Civil Rights Act of 1964. _____ 29 U.S.C. 621-634 (b) (Age Discrimination in Employment Act) _____ 42 U.S.C. 12111 et. seq. (Americans With Disabilities Act) 1. Plaintiff resides at:__________________ _________________ _______________ 1 <<<<<<<<<********>>>>>>>>>>>>> 2_________________ _________________ _________________ _______________ 2. Defendant employer(s) reside or can be served with process at the addresses set forth in the caption above. 3. This Action is brought for employment discrimination, pursuant to one or both of the following laws: a. _____ Title VII of the Civil Rights Act of 1964 for employment discrimination. b. _____ Age Discrimination in Employment Act of 1967, codified at 29 U.S.C. 621-634(b), as amended, for employment discrimination based on age; c. _____ Americans With DisabilitiesAct, codified at 42 U.S.C. 12111 et. seq., for employment discrimination based on disability.Jurisdictionis conferred on this court pursuant to 29 U.S.C. 626(c)(1), 42 U.S.C. 2000e-5, or42 U.S.C. 12 117. If the plaintiff is a federal employee, jurisdiction is conferred on this courtpursuant to 29 U.S.C. 633a(c). 4. Venue is invoked pursuant to 28 U.S.C. 1391. 5. Defendants conduct is discriminatory with respect to the following: a. _____ My race or color, which is_________________ _______________. b. _____ My religion, which is ________________ _________________ __. c. _____ My sex, which is _____ male; _____ female. d. _____ My national origin, which is ________________ ______________. e. _____ My age, in violation of 29 U.S.C. 623. f. _____ My disability or perceived disability, which is ________________ . g. _____ Other as specified below: _________________ _________________ _________________ ___ _________________ _________________ _________________ ___ _________________ _________________ _________________ __. 2<<<<<<<<<********>>>>>>>>>>>>> 3 6. The plaintiff is an employee within the meaning of the above-cited statutes. 7. If this is an age discrimination case, the plaintiff states the following: a. Plaintiff is within the age limits as prescribed by 29 U.S.C. 631(a). b. My age at the time of the alleged discriminatory conduct was __________. c. My date of birth is ________________ ______. 8. The defendant(s) is (are) an employer, employment agency, or labor organization within the meaning of 28 U.S.C. 1343 and 29 U.S. C 630(b)(c) and (d). 9. The defendant(s) is (are) engaged in commerce within the meaning of the above- cited statutes. 10. The conduct complained of in this action concern: a. _____ Failure to employ b. _____ Termination of employment c. _____ Failure to promote d. _____ Unequal terms and conditions of employment e. _____ Reduction in wages f. _____ Retaliation g. _____ Failure to accommodate disability h. _____ Other acts as specified below:_________________ _________________ _________________ ___ _________________ _________________ _________________ ___ _________________ _________________ _________________ ___ _________________ _________________ _________________ ___ _________________ _________________ _________________ ___ 3<<<<<<<<<********>>>>>>>>>>>>> 4 11. The facts surrounding my claim of discrimination are: _________________ _________________ _________________ _______________ _________________ _________________ _________________ _______________ _________________ _________________ _________________ _______________ _________________ _________________ _________________ _______________ _________________ _________________ _________________ ____________ ___ (If more space is needed you may attach additional sheets of 8 X 11" paper.) 12. The alleged discriminatory conduct occurred on or about ________________ ____ at ______________ _________________ _________________ ____________. 13. In accordance with 42 U.S.C. 2000e-5, 29 U.S.C. 626(d) and 29 U.S.C. 633(b), or 42 U.S.C. 12117, more than sixty (60) days have elapsed since filing a charge alleging unlawful discrimination with the Kansas State Division of Human Rights, the Kansas Commission on Human Rights or the Equal Employment Opportunity Commission. 14. In accordance with 28 U.S.C. 1343 or 29 U.S.C. 633a(d), of this is an Age D iscrimination action, a thirty (30) day Notice of Intent to File this action has been given to the Equal Employment Opportunity Commission. 15. I filed charges with the Kansas State Division of Human Rights or the Kansas State Commission on Human Rights regarding the alleged discriminatory act on _________________ ______________. 16. I filed charges with the Equal Employment Opportunity Commission regarding the alleged discriminatory act on ________________ _________________ ____. 17. I filed a Notice of Intent with the Equal Employment Opportunity Commission on _________________ _____________. 18. The Equal Employment Opportunity Commission issued a Notice of Right to Sue 4<<<<<<<<<********>>>>>>>>>>>>> 5 letter (copy attached) which was received by me on or about_________________ . 19. If relief is not granted, plaintiff will be irreparably denied the rights secured by the Age Discrimination in Employment Act of 1967, as amended, by Title VII of the 1964 Civil Rights Act, as amended, or by the Americans With Disability Act. 20. Plaintiff demands trial by jury. Yes_____ No _____ WHEREFORE, plaintiff prays that: a. The court grant the relief stated in 42 U.S.C. 2000e-5, 29 U.S.C. 633a(c), or 42 U.S.C. 12117, including damages in the amount of $________________ . b. The court grant such other legal or equitable relief as the court deems just and proper, including attorneys fees and costs. _________________ _________________ _ Signature of Plaintiff _________________ _________________ _ Name (Print or Type) _________________ _________________ _ Address _________________ _________________ _ City State Zip Code _________________ _______________
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