EEO Complaint Form Age Discrimination

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF MICHIGAN _____________ emaN)s(ffitnialP fo vs. Civil No. ______________ (To be supplied by the Clerk of the Court)Name of Defendant(s) INSTRUCTIONS FOR COMPLETING FORM: If you wish to file a law suit for vi olation of your civil rights because of your age, then you are the plaintiff. The person, company, or union you sue is the defendant. To begin a lawsuit you must file a complaint with the court. This form is to help you follow the Federal Rules of Civil Procedure in filing a complaint under the AGE DISCRIMINATION IN EMPLOYMENT ACT OF 1967 (ADEA). If there is more than one plaintiff or defendant, each must be identi fied by name and address. Each plaintiff must also state the facts of the discriminatory act unless the facts are the same for all plaintiffs. You may not be able to fill in every blank. If you are unable to provid e the requested information, state either "unknown" or "not applicable" or other similar explanation. If y ou need help, ask the Clerk at the filing desk. Please print legibly. COMPLAINT PARTIES 1. Plaintiffs address is: street city county state ( ) zip code phone number 2. Defendants address is: street city county state ( ) zip code phone number <<<<<<<<<********>>>>>>>>>>>>> 2 NATURE OF PROCEEDINGS 3. Plaintiff seeks legal and equitable relief for the denial of certain rig hts securedby the Age Discrimination in Employment Act of 1967, as codified at 29 U SC Sections 621- 634. Such relief is authorized under 29 USC Section 626 (b)(c). JURISDICTION 4. This Court has jurisdiction pursuant to 29 USC Section 626(c)(d). ADDRESS 5. Is the address where the discriminatory act(s) took place the same add ress asfor defendant? _____ yes _____ no. If different from the defendants address, the discriminatory act(s) took place at: street city county state ( ) zip code phone number FACTS If you were not hired because of your age, please complete. Refusal to Hire 6. Provide a brief statement of the facts to include the following: A. Date of application , 20 B. If not hired, the date of refusal to hire , 20 C. If you were not hired because of your age, the names and ages of other applicants who were hired (if known): 2 <<<<<<<<<********>>>>>>>>>>>>> 3 If you were treated differently than other employees because of your age , please complete the following. Difference in Terms and Conditions of Employment Because of Age 7. Provide a brief statement of the facts to include the following: A. Job position plaintiff held at time of discharge, demotion, or other discriminatory act B. Date the act(s) occurred , 20 C. Was this part of a general layoff or reduction in force (if you know)? _____ yes _____ no D. Rate of pay when this occurred $ per hour/per week (please circle) E. Replacements name and age (if known) F. Name and age (if known) of any individual who was treated differently than you because of your age Factual StatementThe following is plaintiffs account of the facts: CAUSE OF ACTION 8. Defendant in committing the above acts has violated the Age Discriminati on inEmployment Act of 1967 in that defendant has discriminated against plain tiff because ofplaintiffs age. 3<<<<<<<<<********>>>>>>>>>>>>> 4 9. Defendants conduct was willful. 10. Charges were filed with the Equal Employment Opportunity Commission on(state the date or best estimate): , 20 Attach a copy of the Charge you filed with the Equal Employment Opportun ity Commission. 11. Charges were filed with the Michigan Department of Civil Rights on (sta te thedate or best estimate): , 20 Attach a copy of the Charge you filed with the Michigan Department of Ci vil Rights. STATUTORY PREREQUISITE 12. Plaintiff has complied with 29 USC Section 626(d)(2) in that plainti ff filed acharge with the Equal Employment Opportunity Commission (check appropri ate letter): A._____Within 300 days after the unlawful incident occurred; or B._____Within 30 days of notice of the end of proceedings under State la w. Note to plaintiff: the time limit for filing is A or B, whichever is earlier. 13. Plaintiff has complied with 29 USC Section 626(d) in that it has been at least 60days since charges were filed with the Equal Employment Opportunity Comm ission. 14. Plaintiff was born on and has complied with day month year 29 USC Section 631 in that Plaintiff was at least 40 years old at the ti me the discriminatory acttook place. JURY TRIAL 15. Plaintiff requests a trial by jury as provided in 29 USC Section 626(c) (2). _____ Yes _____ No 4 <<<<<<<<<********>>>>>>>>>>>>> 5 RELIEF 16. Plaintiff requests the following: Check applicable letters A._____ That all fees, costs or security attendant to this suit be waived; B._____ That the Court grant such relief as may be appropriate, including injunctive orders, damages, costs and attorneys fees; C._____ That the Court grant reinstatement where appropriate. DATED: Signature of Plaintiff 5