Fillable Complaint For Violations Of Fair Labor Standards Complaint for Violation of Fair Labor Standards

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Complaint For Violations Of Fair Labor Standards Complaint for Violation of Fair Labor Standards

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Pro Se 8 (Rev. 12/16) Complaint for Violation of Fair Labor Standards
UNITED STATES DISTRICT COURT
for the
__________ District of __________
__________ Division
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Case No.
(to be filled in by the Clerk’s Office)
Plaintiff(s)
(Write the full name of each plaintiff who is filing this complaint.
If the names of all the plaintiffs cannot fit in the space above,
please write “see attached” in the space and attach an additional
page with the full list of names.)
-v-
Jury Trial:
(check one) ’ Yes ’ No
Defendant(s)
(Write the full name of each defendant who is being sued. If the
names of all the 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 VIOLATION OF FAIR LABOR STANDARDS
I. The Parties to This Complaint
A. The Plaintiff(s)
Provide the information below for each plaintiff named in the complaint. Attach additional pages if
needed.
Name
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address
B. The Defendant(s)
Provide the info
rmation 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.
Page 1 of 6
__________ District of __________
__________ Division
Pro Se 8 (Rev. 12/16) Complaint for Violation of Fair Labor Standards
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)
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)
Page 2 of 6
Pro Se 8 (Rev. 12/16) Complaint for Violation of Fair Labor Standards
C. Place of Employment
The address at which I am employed 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 pursuant to
(check all that apply):
’ Fair Labor Standards Act, as codified, 29 U.S.C. §§ 201 to 209.
’ Relevant state law
’ Relevant city or county law
III. Statement of Claim
State as briefly as possible the facts of your case. You may wish to include further details such as the names of
other persons involved in the events giving rise to your claims. Do not cite any cases. 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.
Nature
of employer’s business:
B. Dates of employment:
C.
Employee’s job title and a description of th
e kind of work done:
D. Rate, method, and frequency of wage payment:
Page 3 of 6
Pro Se 8 (Rev. 12/16) Complaint for Violation of Fair Labor Standards
E. Number of hours actually worked each week in which a violation is claimed:
F. Description of the alleged violation(s) (check all that apply):
’ Failure to pay the minimum wage
(explain)
’ Failure to pay required overtime (explain)
’ Other violation(s) (explain)
G. Date(s) of the alleged violation(s):
H. Additional facts:
Page 4 of 6
Pro Se 8 (Rev. 12/16) Complaint for Violation of Fair Labor Standards
IV. 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.
V. Certification and Closing
Under Federal Rule of Civil Procedure 11, 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 provid
e 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
Page 5 of 6
Pro Se 8 (Rev. 12/16) Complaint for Violation of Fair Labor Standards
Name of Law Firm
Street Address
State and Zip Code
Telephone Number
E-mail Address
Page 6 of 6
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Complaint For Violations Of Fair Labor Standards Complaint for Violation of Fair Labor Standards

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Completed 17 February 2020

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