Pro Se Employment Discrimination Complaint Form

NOTICE TO PRO SE PLAINTIFFS attaching form Complaint (revised 2/20/2013) Representing yourself in Court-called appearing pro se-is difficult for persons without legal training. Before doing so, you should consider finding an attorney to take your case. The following referral services may help you find a lawyer: 1. Atlanta Bar Association (404) 521-0777 (serving Fulton, Cobb, DeKalb, Douglas, Rockdale, Paulding, Henry, Gwinnett, Clayton, Cherokee, Fayette, and Forsyth Counties) Cobb County Lawyer Referral Service (770) 424-2947 (serving Cobb, Douglas, Bartow, Cherokee, and Paulding Counties) DeKalb Bar Association Lawyer Referral Service (404) 373-2580 (serving DeKalb, Fulton, Gwinnett, and Cobb Counties) Attorneys' Confidential Referral Service, Inc. (888) 536-5900 (serving all Counties in Georgia) Atlanta Volunteer Lawyers Foundation (404) 521-0790 http://www.avlf.org 2. 3. 4. 5. If you desire to proceed without a lawyer, the attached form complaint has been prepared for your convenience, but you are not required to use it. Please write clearly and fill it out to the best of your ability. However, completion and filing of this form is no guarantee that your case will succeed. You must keep the Clerk of Court informed as to any change in your address or telephone number. You must also follow the Federal Rules of Civil Procedure and the Local Rules of this Court. You may obtain a copy of the Federal Rules of Civil Procedure in most public libraries or at the following website: http://www.uscourts.gov/uscourts/rules/civil-procedure.pdf. You may review this Court's Local Rules in the Clerk's Office, purchase a copy from the Clerk's Office, or access this Court's Local Rules at the following website: http://www.gand. uscourts.gov/pdfINDGARulesCV.pdf. American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF GEORGIA _ _ _ _ _ _ DIVISION (Print your full name) Plaintiffpro se, v. (to be assigned by Clerk) CIVIL ACTION FILE NO. (Print full name of each defendant; an employer is usually the defendant) Defendant( s). PRO SE EMPLOYMENT DISCRIMINATION COMPLAINT FORM Claims and Jurisdiction 1. This employment discrimination lawsuit is brought under (check only those that apply): Title VII of the Civil Rights Act of 1964,42 U.S.C. §§ 2000e et seq., for employment discrimination on the basis of race, color, religion, sex, or national origin, or retaliation for exercising rights under this statute. NOTE: To sue under Title VII, you generally must have received a notice of right-to-sue letter from the Equal Employment Opportunity Commission ("EEOC"). Page 1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Age Discrimination in Employment Act of 1967, 29 U.S.C. §§ 621 et seq., for employment discrimination against persons age 40 and over, or retaliation for exercising rights under this statute. NOTE: To sue under the Age Discrimination in Employment Act, you generally must first file a charge of discrimination with the EEOC. Americans With Disabilities Act of 1990,42 U.S.C. §§ 12101 et seq., for employment discrimination on the basis of disability, or retaliation for exercising rights under this statute. NOTE: To sue under the Americans With Disabilities Act, you generally must have received a notice of right-to-sue letter from the EEOC. Other (describe) 2. This Court has subject matter jurisdiction over this case under the above-listed statutes and under 28 U.S.C. §§ 1331 and 1343. Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Parties 3. Plaintiff. Name Address Print your full name and mailing address below: 4. Defendant( s). Print below the name and address of each defendant listed on page 1 of this form: Name Address Name Address Name Address Location and Time Page 3 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 6. When did the alleged discrimination occur? (State date or time period) Administrative Procedures 7. Did you file a charge of discrimination against defendant(s) with the EEOC or any other federal agency? Yes No If you checked "Yes," attach a copy of the charge to this complaint. 8. Have you received a Notice of Right-to-Sue letter from the EEOC? - - Yes - - No If you checked "Yes," attach a copy of that letter to this complaint and state the date on which you received that letter: 9. If you are suing for age discrimination, check one of the following: 60 days or more have elapsed since I filed my charge of age discrimination with the EEOC Less than 60 days have passed since I filed my charge of age discrimination with the EEOC Page 4 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 10. If you were employed by an agency of the State of Georgia or unsuccessfully sought employment with a State agency, did you file a complaint against defendant(s) with the Georgia Commission on Equal Opportunity? - - Yes - - No _ _ Not applicable, because I was not an employee of, or applicant with, a State agency. If you checked "Yes," attach a copy ofthe complaint you filed with the Georgia Commission on Equal Opportunity and describe below what happened with it (i.e., the complaint was dismissed, there was a hearing before a special master, or there was an appeal to Superior Court): 11. If you were employed by a Federal agency or unsuccessfully sought employment with a Federal agency, did you complete the administrative process established by that agency for persons alleging denial of equal employment opportunity? - - Yes - - No _ _ Not applicable, because I was not an employee of, or applicant with, a Federal agency. In If you checked "Yes," describe below what happened administrative process: that Page 5 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Nature of the Case 12. The conduct complained about in this lawsuit involves (check only those that apply): failure to hire me failure to promote me demotion reduction in my wages working under terms and conditions of employment that differed from similarly situated employees harassment retaliation termination of my employment failure to accommodate my disability other (please specify) _ _ _ _ _ _ _ _ _ _ _ _ __ 13. I believe that I was discriminated against because of (check only those that apply): my race or color, which is _ _ _ _ _ _ _ _ _ _ _ __ my religion, which is _ _ _ _ _ _ _ _ _ _ _ _ _ __ my sex (gender), which is male female my national origin, which is _ _ _ _ _ _ _ _ _ _ _ __ my age (my date of birth is _ _ _ _ _ _ _ _ _ _ _ _J my disability or perceive