Charge of Discrimination Complaint

CHARGE OF DISCRIMINATION COMPLAINT

Filing Agency:   Charge Number:

Complainant Name:   Telephone:

Complainant Address:

Respondent (Employer/Entity) Name:   Telephone:

Respondent Address:

RECITALS

WHEREAS, Complainant asserts that Respondent is an employer within the meaning of applicable anti-discrimination statutes and regulations, and that Respondent engaged in actions or omissions affecting Complainant's employment; and

WHEREAS, Complainant alleges that Respondent's actions constitute unlawful discrimination on one or more protected bases and that administrative relief and investigative remedy are sought; and

WHEREAS, Complainant seeks formal investigation, conciliation where appropriate, and full relief permitted by law.

NOW, THEREFORE

Complainant hereby charges Respondent with unlawful employment practices and submits the following statements, allegations, and requested relief for administrative review and resolution.

1. JURISDICTION

This charge is filed within the time and procedural limits required by applicable administrative law and statutes. Complainant asserts that this agency has jurisdiction to receive, investigate, and attempt to resolve this charge, and that all conditions precedent to the filing of this charge have been satisfied or waived.

2. PARTIES

Complainant is: employed or affected by Respondent in the capacity indicated above. Respondent employed approximately employees at all relevant times.

3. STATEMENT OF FACTS

Date(s) of alleged discriminatory act(s):   Last date of alleged harm (if different):

4. BASIS OF DISCRIMINATION

Complainant asserts discrimination on one or more of the following protected bases (check all that apply):

Race   Color   National origin   Sex   Pregnancy   Gender identity

Sexual orientation   Age   Disability   Religion   Genetic information   Retaliation

If other, specify:

5. NATURE OF ALLEGED UNLAWFUL PRACTICES

Complainant alleges that Respondent engaged in the following unlawful practices (check all that apply) and provide specifics in the statement above:

Disparate treatment   Harassment   Hostile work environment   Disparate impact

Failure to accommodate   Retaliation   Constructive discharge   Other

If other, specify:

6. RELIEF REQUESTED

Complainant requests that the agency investigate this charge and seek the following remedies as appropriate to the findings:

Reinstatement   Back pay   Front pay   Compensatory damages

Punitive damages   Injunctive relief   Attorney's fees and costs   Other

7. INVESTIGATION AND CONCILIATION

Complainant requests that the agency investigate all matters alleged herein and pursue conciliation, mediation, or other administrative remedies where appropriate. Complainant understands that the agency may request additional information, conduct interviews, and request documents from either party as part of the investigatory process.

8. CERTIFICATION

I certify under penalty of perjury under the laws of the applicable jurisdiction that the facts set forth in this Charge of Discrimination Complaint are true and correct to the best of my knowledge, information, and belief.

Date of filing:

9. NOTICES

10. AMENDMENTS AND WAIVER

This Charge may be amended to add allegations and parties upon leave of the agency. No failure or delay by either party in exercising any right, power or privilege under this Charge shall operate as a waiver, except by written instrument signed by the waiving party.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

Governing Law: This Charge shall be governed by the laws and administrative rules applicable to discrimination complaints filed with this agency. Entire Agreement: This document constitutes the entire written charge submitted by Complainant to the agency and supersedes any prior written statements regarding the matters asserted herein. Severability: If any provision of this Charge is held invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect.

12. INVESTIGATIVE AUTHORIZATION

Complainant authorizes the agency to obtain and review employment records, personnel files, wage and benefit records, calendar entries, electronic communications to the extent permitted, and any other documents necessary to investigate the allegations set forth in this Charge.

ADDITIONAL INFORMATION

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