Complaint Pursuant To The Americans With Disabilities Act

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK ) ) ) ) ) ) ) Plaintiff(s) vs. Civil Case No.: COMPLAINT PURSUANT TO THE AMERICANS WITH DISABILITIES ACT Defendant(s) Plaintiff(s) demand(s) a trial by: ____ JURY _____ COURT (Select only one). Plaintiff(s) in the above-captioned action, allege(s) as follows: JURISDICTION 1. This is a civil action seeking judgment, relief and/or damages brought pursuant to the Americans with Disabilities Act, 42 U.S.C. § 12101 et seq., as amended, for discrimination based upon a disability and the failure to accommodate same. This Court has jurisdiction of this action pursuant to 28 U.S.C. §§ 1331 and 1343(4). PARTIES 2. a. Plaintiff: Address: b. Plaintiff: Address: Additional Plaintiffs may be added on a separate sheet of paper. American LegalNet, Inc. www.FormsWorkFlow.com 3. a. Defendant: Official Position: Address: b. Defendant: Official Position: Address: Additional Defendants may be added on a separate sheet of paper. 4. My disability is as follows: American LegalNet, Inc. www.FormsWorkFlow.com 5. The conduct complained of in this action involves: (Check all that apply) (A) (B) (C) (D) (E) (G) Failure to employ. Termination of employment. Denial of participation in public service or program. Failure to make alterations to accommodate disability. Retaliation. Other acts as specified below: 6. FACTS On the following page, set forth the facts of your case which substantiate your claim of discrimination. List the events in the order they happened, naming defendants involved, dates and places. Note: Each fact should be stated in a separate paragraph; paragraphs should be numbered sequentially. You must include allegations of wrongful conduct as to EACH and EVERY defendant in your complaint. You may use additional sheets as necessary. American LegalNet, Inc. www.FormsWorkFlow.com 7. PRAYER FOR RELIEF WHEREFORE, plaintiff(s) request(s) that this Court grant the following relief: I declare under penalty of perjury that the foregoing is true and correct. DATED: Signature of Plaintiff(s) (all Plaintiffs must sign) American LegalNet, Inc. www.FormsWorkFlow.com