274B Amended
Complaint/Questionnaire Regarding
Unfair Immigration-Related Employment Practices
Read directions carefully.
Attach 5 copies of the charge filed with the Office of Special Counsel.
Attach 5 copies of the letter of determination from the Office of Special Counsel. Sign your name and date on the last paqe.
FILL IN THE BLANKS
_______________________________________.
1) My name is first / middle / last
Other name(s) that I use is/are : __________________________.
__________________________.
My address is: _____________________________________________.
number street
__________________________________________________.
city state zip code
My telephone number is:__________________________.
(area code) phone number
CHECK ONLY ONE
2) I am: _____ a United States Citizen
_____ a United States National
_____ an Alien authorized to be employed in the United States
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3) I was born in the country of: _________________________________.
4 ) I am a citizen of: ____________________________________________.
5) I applied for naturalization on: ____/_____________/______________.
day month year
6) I became a naturalized citizen on: ____/_____________/______________.
day month year
7) I obtained my permanent residence status on:
____/_____________/______________.
day month year
CHECK ONLY ONE
8) I have been discriminated against because of my national
origin. YES NO
CHECK ONLY ONE
9) I have been discriminated against because of my
citizenship status. YES NO
FILL IN THE BLANKS
10) The Business/Employer who I claim discriminated against
me is:
_______________________________________________________.
name
___________________________________________________________.
number street
___________________________________________________________.
city state zip code
Other address used by business/employer
___________________________________________.
number street
_______________________________________________.
city state zip code
11) On ______/________________/_______, I applied for or worked at
day month year the business/employer.
12) The job was (describe the job and duties):____________
_________ __________________________________________________
____________________________________________________________.
CHECK ONLY ONE
13) I was knowingly and intentionally not hired:
YES NO
IF YOUR ANSWER TO QUESTION 13 IS YES, ANSWER PARTS a, b, c, d and e below. COMPLETE THE REST OF THE COMPLAINT FORM.
CHECK ONLY ONE a) I was not hired because of my:
_________ citizenship status
________ national origin
________ citizenship status AND national origin
FILL IN THE BLANK
b) State the reason you were not hired:
____________________________________________________________
____________________________________________________________
____________________________________________________________
CHECK ONLY ONE
c) I was qualified for the job and the business/employer was looking for workers. YES NO
d) After I was not hired, the job remained open and the business/employer continued taking applications from other people with my qualifications. YES NO
e) I want to be hired by the business/employer.
YES NO
YOUR ANSWER TO THIS NEXT QUESTION WILL NOT AFFECT YOUR RIGHT TO BRING THIS ACTION.
CHECK ONLY ONE
14) I was knowingly and intentionally fired.
YES NO
IF YOUR ANSWER TO QUESTION 14 IS YES, COMPLETE PARTS a, b, c, d, e and f below. COMPLETE THE REST OF THE COMPLAINT.
CHECK ONLY ONE
a) I was fired because of my:
________ citizenship status
__________ national origin
__________ citizenship status AND national origin
b) State the reason you were fired: _____________________________
_________________________________________________________________
_________________________________________________________________
FILL IN THE BLANKS
c) I was fired on: ____/___________/____
day month year
CHECK ONLY ONE
d) I was qualified for the job but was fired
anyway. YES NO
e) Although I was fired, other workers in my situation
of different nationalities or citizenship were not
fired. YES NO
f) I want to be re-hired by the business/employer.
YES NO
YOUR ANSWER TO THE NEXT QUESTION WILL NOT AFFECT YOUR RIGHT TO
BRING THIS ACTION
15) I was intimidated, threatened, coerced or retaliated against because I filed or planned to file a complaint, or to keep me from assisting someone else to file a complaint.
YES NO
IF YOUR ANSWER TO QUESTION 15 IS YES, COMPLETE PART a. COMPLETE THE REST OF THE COMPLAINT.
a) Explain what happened to you:__________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
16) The Business/Employer refused to accept the documents that I presented to show I can work in the United States.
YES NO
IF YOUR ANSWER TO QUESTION 16 IS YES, COMPLETE PART a. COMPLETE THE REST OF THE COMPLAINT.
FILL IN THE BLANKS
a) The Business/Employer refused to accept the following documents: _____________________________________________
________________________________________________________
________________________________________________________.
17) The Business/Employer asked me for too many or wrong documents than required to show that I am authorized to work in the United States. YES NO
IF YOUR ANSWER TO QUESTION 17 IS YES, COMPLETE PART a. COMPLETE THE REST OF THE COMPLAINT.
FILL IN THE BLANKS
a) The Business/Employer asked me for the following documents:
__________________________________________________________
__________________________________________________________
__________________________________________________________.
FILL IN THE BLANKS
18) I filed a charge with the Office of Special Counsel on:
___/_________/_____.
day month year
IT IS IMPORTANT THAT YOU ATTACH A COPY OF THE CHARGE
CHECK ONLY ONE
19) The Office of Special Counsel sent me a letter telling me
that I now can file my complaint with the Office of the
Chief Administrative Hearing Officer. ______ YES _____NO
IF YOU ANSWERED YES, IT IS IMPORTANT THAT YOU ATTACH A COPY OF THIS LETTER
20) I want back pay. ______YES______ NO
FILL IN THE BLANKS
21) I want back pay from:_______/_____________/__________
day month year
Complainant respectfully requests:
That the Office of the Chief Administrative Hearing Officer serve the complaint and notice of hearing on the Respondent and assign an Administrative Law Judge to consider the complaint and to preside at a hearing as soon as practicable;
That the Administrative Law Judge grant the relief available as contained within 28 C.F.R. Part 68.52 (Decision and Order of the Administrative Law Judge.)
22) YOU MUST SIGN AND DATE BELOW:
Sign : ___________________________________________________
first / middle / last
Date:_____/______________/______
day month year
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