Declaration of Charging Party
I [Enter Name] (“Affiant”), who being duly sworn according to law, do make an oath and states
as follows:
1. I am an African- American woman who resides at [Enter Address].
2. My complaint is against the Hospice Plus, where I was subjected to discrimination and
was retaliated upon because of my race.
3. The Charge of Discrimination and the Brief in support of the charge for discrimination
outline the particulars and/or incidences showing how I was discriminated upon.
4. Upon my information and belief, I have duly stated any and all information I have with
regards to my Complaint.
5. I understand that an investigation may be done on the facts stated in my Charge of
Discrimination; the Brief in support of the charge for discrimination; and this Affidavit. I
further understand that a civil and/or criminal action may be brought against the
perpetrators of the discrimination for their conduct as alleged in the foresaid documents.
6. I agree to testify, declare, depose, certify or acknowledge the truth of any or all of the
statements contained herein before a court of competent jurisdiction, officer or person
thereof.
7. I recognize that any false statement or other misrepresentation made in this Affidavit,
may subject me to civil and/or criminal penalties. I further understand that I may not
recover for any relief I claim for the alleged discriminatory conduct, if I provide false
information herein.
8. I hereby swear under the penalty of perjury that the facts referred to in this affidavit are
true, complete and correct.
Sincerely,
________________
[ENTER NAME]
For the Notary:
Sworn to before me this _________ day of _______________________
[Signature]
____________________________
Notary Public
State of [Enter State]
My Commission Expires: ___________
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