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EEOC Form 5 (11/09)
Charge Of Discrimination	Charge Presented To:	Agency(ies) Charge No(s):
This form is affected by the Privacy Act of 1974. See enclosed Privacy Act Statement and other information before completing this form.	FEPA
EEOC
[fepa]	and EEOC
State or local Agency, if any
Name (indicate Mr., Ms., Mrs.)	Home Phone (Incl. Area Code)	Date of Birth
[plfNm]	[plfPhn]	[plfDOB]
Street Address City, State and ZIP Code
[plfAddy]
Named is the Employer, Labor Organization, Employment Agency, Apprenticeship Committee, or State or Local Government Agency That I Believe Discriminated Against Me or Others. (If more than two, list under PARTICULARS below.)
Name	No. Employees, Members	Phone No. (Include Area Code)
[defNmA]	15+	[defPhnA]
Street Address City, State and ZIP Code
[defAddyA]
Name	No. Employees, Members	Phone No. (Include Area Code)
[defNmB]	15+	[defPhnB]
Street Address City, State and ZIP Code
[defAddyB]
Name	No. Employees, Members	Phone No. (Include Area Code)
[defNmC]	15+	[defPhnC]
Street Address City, State and ZIP Code
[defAddyC]
DISCRIMINATION BASED ON (Check appropriate box(es).)	DATE(S) DISCRIMINATION TOOK PLACE
Earliest	Latest
RACE	COLOR	SEX	RELIGION	NATIONAL ORIGIN	[stDt]	[endDt]
RETALIATION	AGE	DISABILITY	GENETIC INFORMATION
OTHER (Specify)	CONTINUING ACTION
THE PARTICULARS ARE (If additional paper is needed, attach extra sheet(s)): \
[shortSummary]
I want this charge filed with both the EEOC and the State or local Agency, if any. I will advise the agencies if I change my address or phone number and I will cooperate fully with them in the processing of my charge in accordance with their procedures.	NOTARY – When necessary for State and Local Agency Requirements
[28 USC §1746, §92.525 FS]
I swear or affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.
I declare under penalty of perjury that the above is true and correct.
SIGNATURE OF COMPLAINANT
[hoy]
SUBSCRIBED AND SWORN TO BEFORE ME THIS DATE (month, day, year)
Date	Charging Party Signature	[28 USC §1746, §92.525 FS]

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