FOR THE _______ DISTRICT OF ____

_________ DIVISION

XXXX,                                   Plaintiff     vs.  XXXX,                                 Defendant   Case No. ______________ Honorable: _____________


  1. COMES NOW Plaintiff XXZXX , with this complaint against the Defendant XXX, as follows:  


  • Complainant, XXXX, is an individual of address [ENTER ADDRESS].
  • Defendant, STEVEN GROMAN is is an individual of address [ENTER ADDRESS].


  • This court has federal question jurisdiction pursuant to 28 U.S.C § 1331 since it involves the violations of federal law. Plaintiff brings the suit under 18 U.S.C § 241.  
  • Venue is proper in this district under 28 U.S.C. § 1391 as Plaintiff and/or Defendant is subject to personal jurisdiction in this state. Plaintiff and/or Defendant lives within the jurisdiction of this Court. Besides, a substantial part of the acts and omissions forming the basis of these claims occurred in the District of California and arose from the actions or inactions of the Defendants.


  • On or about XXXX, Plaintiff filed a Complaint through the webpage against his employer alleging retaliation against him/her after Plaintiff found health and safety issues, which the employer had failed to respond to for 407 days.
  • By XXXX, Plaintiff had not received any communication from OSHA. Plaintiff therefore called the Pittsburgh office to seek for an update of the case. Plaintiff was informed that his Complaint was not in the system. Accordingly, Plaintiff had to submit the Complaint again.
  • On or about XXX, Defendant tried interviewing Plaintiff. However, the interview could not proceed since Defendant claimed that he could not get Plaintiff. Consequently, Defendant asked Plaintiff to record a statement, which Plaintiff sent.
  • Consequently, Defendant and Plaintiff had interviews consecutively on XXXX. In the said interview, Defendant was dismissive of Plaintiff’s allegations. He cut Plaintiff short as he/she was explaining his case. For instance, he stated that he did not want to hear anything “that happened on another country or dates more than two years”. It is worth noting that Plaintiff needed to provide a background to his allegations, so that he may be able to establish his case.  




WHEREFORE, the Plaintiff is entitled to damages from the Defendant, and he hereby prays that judgment be entered in his favor and against the Defendant as follows:

Complainant seeks the following remedies:

Respectfully submitted:

 ______________________________ XXX ENTER ADDRESS Pro se

Dated: __________


I, [ENTER NAME], certified on this ______day of ________ XXXX, I deposited a true copy of the above to the Defendants by placing the documents with prepaid postage in the United States mailbox address.

 ______________________________ XXX ENTER ADDRESS Pro se

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