Complaint Form For Penalty Or Termination Due To Jury Duty printable pdf download

Complaint Form For Penalty Or Termination Due To Jury Duty

New York State Office of the Attorney General

Labor Bureau

120 Broadway, 26

Floor

New York, NY 10271

(212) 416-8700

COMPLAINT FORM for penalty or termination due to jury duty

1. Please fill out this form only if you think that you have been penalized or terminated/fired from

your job because you had to serve jury duty

2. Please write clearly

3. If you submit any documents with the complaint form, please send copies, not originals

4. After filling out and signing, return by mail or in person to the Labor Bureau

Complainant Information

Name: _______________________________

Phone number: ___________________________

Street Address: ________________________________________________________________

City: ____________________________________

State: ________

Zip: ______________

Complaint

Employer: _______________________________

Phone number: _____________________

Street Address: _________________________________________________________________

City: _________________________________

State: ________

Zip: __________________

Dates of Jury Duty Service: _________________________________________________________

Court in which Jury Duty was served: _________________________________________________

In the space below, please describe the basis for your complaint (ex. circumstances and date of

termination, nature of penalty, etc.) and other information you think would be helpful. Please use

the back or attach additional sheets if necessary.

READ THE FOLLOWING BEFORE SIGNING BELOW

The above complaint is true and accurate to the best of my knowledge. I understand that any

false statements made in this complaint are punishable as a Class A Misdemeanor under Penal Law

Section 175.30 and/or Section 210.45.

Complaint Form For Penalty Or Termination Due To Jury Duty