14. (a) Is there a collective bargaining agreement that may apply to the conduct that is
alleged to have violated the Law? Yes No
(b) If you checked "Yes" in question 14(a), please list all of the clauses alleged to apply and attach a copy of each.
(c) Is there a grievance concerning this matter pending?
Yes No
15. Without limiting your rights to later amend your remedial request, please explain what remedy you seek. Include the
amount of any financial remedy to which you claim entitlement.
16. Have you attempted to settle this case?
If not, why not? Yes No
Note: The DLR may decline to issue a complaint unless reasonable settlement efforts have been made by
the charging party. 456 CMR 15.04(1).
17. Name 18. Representative to contact 20. Telephone Number
19. Address (street and No., city/town, state, and ZIP code) 21. Fax Number
22. The Charging Party is an:
Individual Employee Organization Employer
I have read the above charge of prohibited practice and swear under the pains and penalties of perjury that the
information contained in it is true and complete to the best of my knowledge and belief.
Name (print) Signature Title (if any)
Address (street and no., city/town, state, and ZIP code) Telephone Number
I hereby certify that I have served a copy of this Charge of Prohibited Practice on the following representative of the
opposing party.
Name Address (street and no., city/town, state, and ZIP code)
Method of Service
In hand First Class Mail Other (specify): ___________________
Signature of Person making Certification Telephone Number
The DLR does not discriminate on the basis of disability in access to its services. Inquiries, complaints or requests,
including requests for auxiliary aids and information regarding access features should be directed to the DLR FORM-005 (page 2)
ADA Coordinator (617) 626-7132. This document is
available in alternative formats. Revised 08/13
Telephone Number
CERTIFICATE OF SERVICE
DECLARATION
INFORMATION ON CHARGING PARTY
