Form 5B-2: Complaint—Age Discrimination and Retaliation
IN THE UNITED STATES DISTRICT COURT
FOR THE ___________ DISTRICT OF _____________
John Doe, )
) Case No.
) JURY DEMAND
XYZ, Inc., )
Complaint and Jury Demand
Plaintiff, John Doe, by his attorney, complains against Defendant, XYZ, Inc., (hereinafter,
“Defendant”) as follows:
Nature of the Action
1. This is an action brought pursuant to the Age Discrimination in Employment Act (the
“ADEA”), 29 U.S.C. §626, et seq. for age discrimination and retaliation for having complained of age
2. Doe, age 53, is an individual residing in ______________.
3. At all relevant times, Doe was an employee of Defendant.
4. On information and belief, Defendant is a Delaware corporation with its principal place of
business in ____________.
5. At all times relevant to the allegation in this Complaint, Defendant operated from a facility in
6. Defendant is principally engaged in the business of distribution of widgets to national
department store chains.
7. At all relevant times, Defendant employed more than 20 people.
Jurisdiction and Venue
8. This Court has jurisdiction over this matter purs uant to 28 U.S.C. §1331 as this matter
involves a federal question based upon the ADEA.
9. The ________________ is the proper venue for this action pursuant to 28 U.S.C. §1391 (b)(1)
and (b)(2) because this is the District and Division in which Doe resides and in which a substantial
part of the events or omissions giving rise to the claims occurred.
10. On [date], Doe filed a charge of discrimination against Defendant with the Equal
Employment Opportunity Commission (“EEOC”).
11. More than sixty days have elapsed since Doe filed his charge with the EEOC.
12. Doe received a right to sue letter dated [date] and fewer than ninety days have elapsed since
Doe received same.
13. Doe was born in [year] and was 52 years old at the time he filed his charge of discrimination.
14. Doe’s employment background includes 29 years of widget sales experience.
[month, year]-[month, year]
15. Doe began working for Defendant in [month, year] as a Territory Sales Representative.
16. Doe served as a Territory Sales Representative for Defendant through [year].
17. In or about [year], Doe was promoted to National Account Sales Executive.
18. Doe continued as a National Account Sales Executive until [month, year] when he was
promoted to National Channel Manager.
19. As a National Channel Manager, Doe managed and controlled operations of channels of
business which represented over $20,000,000 in company sales.
20. In or about [month, year], Doe received a memo stating the sales obj ectives for each
customer for the period of [month, year] through [date] (“the memo”).
21. The memo stated that by meeting the sales goals, Doe had an opportunity to earn up to
45% of his base salary as bonus.
22. At or about the end of [year], based on the sales calculations, Doe earned and received the
maximum bonus amount, 45% of his base salary.
23. At or about the end of [year], Defendant took away some of Doe’s high performing accounts
and reassigned them to a younger employee.
24. At or about the end of [year], Defendant assigned Doe an unprofitable account.
25. Throughout his employment at Defendant, Doe met and/or exceeded Defendant’s
26. On or about [date], Defendant notified Doe it had eliminated his position.
27. After Defendant terminated Doe, it reassigned his job functions, responsibilities and
accounts to another younger employee.
COUNT I: AGE DISCRIMINATION
28. Doe realleges and incorporates in this Count I paragraphs 1-27.
29. Doe’s age was a determining factor in Defendant’s decision to terminate Doe.
30. Defendant knowingly and willfully discriminated against Doe on the basis of his age in
violation of the ADEA.
COUNT II: RETALIATION
31. Doe realleges and incorporates in this Count II paragraphs 1-30.
32. In [month, year], Doe complained to Defendant of age discrimination.
33. In or about [month, year], [name of employee] resigned from Defendant and on [date],
Plaintiff applied for her position.
34. Defendant refused to rehire Doe for [employee]’s position.
35. Defendant’s refusal to rehire Doe for [employee]’s position was in retaliation against Doe for
his having complained of age discrimination.
WHEREFORE, Doe respectfully requests the following relief:
Entry of judgment in favor of Doe and against Defendant;
1. Back pay;
2. Reinstatement, or in the alternative, front pay;
3. Liquidated damages pursuant to 29 U.S.C. §626(b);
4. Attorneys fees and costs; and
5. Other such relief as may be appropriate to effectuate the purposes of the ADEA.