Pro Se 7 (Rev. 10/16) Complaint for Employment Discrimination
United States District Court
for the
NORTHERN DISTRICT OF ALABAMA
_________________________________________________ }
Plaintiff, }
(Write your full name. No more than one plaintiff may be named in a pro se }
complaint) }
}
}
v. } Case No.:_______________________
} (to be filled in by the Clerk's Office)
}
} JURY TRIAL ☐ Yes ☐ No
}
}
}
________________________________________ }
}
Defendant(s), }
(Write the full name of each defendant who is being sued. If the names of all
defendants cannot fit in the space above, please write “see attached” in the }
space and attach an additional page with the full list of names) }
COMPLAINT FOR EMPLOYMENT DISCRIMINATION
I. The Parties to This Complaint
A. The Plaintiff
Name
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)
☐ Check here to receive electronic notice through the e-mail listed above. By
checking this box, the undersigned consents to electronic service and waives
the right to personal service by first class mail pursuant to Federal Rule of
Civil Procedure 5(b)(2), except with regard to service of a summons and
complaint. The Notice of Electronic Filing will allow one free look at the
document, and any attached PDF may be printed and saved.
Date Participant Signature
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Pro Se 7 (Rev. 10/16) Complaint for Employment Discrimination
II. Basis for Jurisdiction
B. The Defendant(s)
Provide the information below for each defendant named in the complaint,
whether the defendant is an individual, a government agency, an organization or a
corporation. For an individual defendant, include the person’s job or title (if
known). Attach additional pages if needed.
Defendant No. 1
Name
Job or Title (if known)
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)
Defendant No. 2
Name
Job or Title (if known)
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)
Defendant No. 3
Name
Job or Title (if known)
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)
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Pro Se 7 (Rev. 10/16) Complaint for Employment Discrimination
Defendant No. 4
Name
Job or Title (if known)
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)
C. Place of Employment
The address at which I sought employment or was employed by the defendant(s)
is:
Name
Street Address
City and County
State and Zip Code
Telephone Number
II. Basis for Jurisdiction
This action is brought for discrimination in employment pursuant to (check all that
apply):
☐ Title VII of the Civil Rights Act of 1964, as codified, 42 U.S.C. §§ 2000e to
2000e-17 (race color, gender, religion, national origin).
(Note: In order to bring suit in federal district court under Title VII, you must
first obtain a Notice of Right to Sue letter from the Equal Employment
Opportunity Commission.)
☐ Age Discrimination in Employment Act of 1967, as codified, 29 U.S.C. §§ 621 to
634.
(Note: In order to bring suit in federal district court under the Age
Discrimination in Employment Act, you must first file a charge with the Equal
Employment Opportunity Commission.)
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Pro Se 7 (Rev. 10/16) Complaint for Employment Discrimination
☐ Americans with Disabilities Act of 1990, as codified, 42 U.S.C. §§ 12112 to
12117.
(Note: In order to bring suit in federal district court under the Americans with
Disabilities Act, you must first obtain a Notice of Right to Sue letter from the
Equal Employment Opportunity Commission.)
☐ Other federal law (specify the federal law):
Relevant state law (specify, if known):
Relevant city or county law (specify, if known):
III. Statement of Claim
Write a short and plain statement of the claim. Do not make legal arguments. State as
briefly as possible the facts showing that plaintiff is entitled to the damages or other relief
sought. State how each defendant was involved and what each defendant did that caused
the plaintiff harm or violated the plaintiff’s rights, including the dates and places of that
involvement or conduct. If more than one claim is asserted, number each claim and write
a short and plain statement of each claim in a separate paragraph. Attach additional pages
if needed.
A. The discriminatory conduct of which I complain in this action includes (check all
that apply):
☐ Failure to hire me
☐ Termination of my employment
☐ Failure to promote me
☐ 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 Opportunity Commission can be considered by the federal
district court under the federal employment discrimination statutes.)
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Pro Se 7 (Rev. 10/16) Complaint for Employment Discrimination
B. It is my best recollection that the alleged discriminatory acts occurred on date(s):
C. I believe that defendant(s) (check one):
☐ is/are still committing these acts against me
☐ is/are not still committing these acts against me
D. Defendant(s) discriminated against me based on my (check all that apply and
explain):
☐ race
☐ color
☐ gender/sex
☐ religion
☐ national origin
☐ age (year of birth)
(only when asserting a claim of age discrimination)
☐ disability or perceived disability (specify disability)
E. The facts of my case are as follows. Attach additional pages if needed.
(Note: As additional support for the facts of your claim, you may attach to this
complaint a copy of your charge filed with the Equal Employment Opportunity
Commission, or the charge filed with the relevant state or city human rights
division.)
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Pro Se 7 (Rev. 10/16) Complaint for Employment Discrimination
IV. Exhaustion of Federal Administrative Remedies
A. It is my best recollection that I filed a charge with the Equal Employment
Opportunity Commission or my Equal Employment Opportunity counselor
regarding the defendant’s alleged discriminatory conduct on (date):
B. The Equal Employment Opportunity Commission (check one):
☐ has not issued a Notice of Right to Sue letter
☐ issued a Notice of Right to Sue letter, which I received on (date):
(Note: Attach a copy of the Notice of Right to Sue letter from the Equal
Employment Opportunity Commission to this complaint.)
C. Only litigants alleging age discrimination must answer this question:
Since filing my charge of age discrimination with the Equal Employment
Opportunity Commission regarding the defendant’s alleged discriminatory
conduct (check one):
☐ 60 days or more have elapsed
☐ less than 60 days have elapsed
V. Relief
State briefly and precisely what damages or other relief the plaintiff asks the court to
order. Do not make legal arguments. Include any basis for claiming that the wrongs
alleged are continuing at the present time. Include the amounts of any actual damages
claimed for the acts alleged and the basis for these amounts. Include any punitive or
exemplary damages claimed, the amounts, and the reasons you claim you are entitled to
actual or punitive money damages.
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Pro Se 7 (Rev. 10/16) Complaint for Employment Discrimination
VI. Certification and Closing
Under Rule 11 of the Federal Rules of Civil Procedure, by signing below, I certify to the
best of my knowledge, information, and belief that this complaint: (1) is not being
presented for an improper purpose, such as to harass, cause unnecessary delay, or
needlessly increase the cost of litigation; (2) is supported by existing law or by a
nonfrivolous argument for extending, modifying, or reversing existing law; (3) the factual
contentions have evidentiary support or, if specifically so identified, will likely have
evidentiary support after a reasonable opportunity for further investigation or discovery;
and (4) the complaint otherwise complies with the requirements of Rule 11.
A. For Parties Without an Attorney
I agree to provide the Clerk’s Office with any changes to my address where case-
related papers may be served. I understand that my failure to keep a current
address on file with the Clerk’s Office may result in the dismissal of my case.
Date of Signing:
Signature of Plaintiff:
Printed Name of Plaintiff:
B. For Attorneys
Date of Signing:
Signature of Attorney:
Printed Name of Attorney:
Bar Number:
Name of Law Firm:
Street Address:
State and Zip Code:
Telephone Number:
E-mail Address:
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