Revised Form E-58

U.S. Department of Justice
Executive Office for Immigration Review
Office of the Chief Administrative Hearing Officer

OMB#1125-0016

Unfair Immigration-Related Employment
Practices Complaint Form

Unfair Immigration-Related Employment Practices Complaint Form

FORM INSTRUCTIONS
Please read all of the directions carefully. Before you file a complaint with our office, you must have first:
1) Filed a charge with the Immigrant and Employee Rights Section (IER) of the Department of Justice,
and
2) Received a letter from IER telling you that you may now file your own complaint with the Office of
the Chief Administrative Hearing Officer (OCAHO). Please note that your complaint must be filed
with OCAHO within ninety (90) days of receiving the letter from IER.
If you need more space to respond to a question, you may attach additional sheets. Please indicate clearly which
question(s) you are responding to on any additional sheets and number each additional sheet.
If you complete this form by hand, please write using only blue or black ink.
When you have completed the complaint, please return it, and the required documents below, to:
United States Department of Justice
Executive Office for Immigration Review
Office of the Chief Administrative Hearing Officer
5107 Leesburg Pike, Suite 2519
Falls Church, VA 22041
CONTACT INFORMATION
If you have any questions about this form, call OCAHO at 703-305-0864 (Mon.-Fri. 7:00am-4:00pm).
If you need to contact IER, call the IER Worker Hotline at 1-800-255-7688 (toll free) or 1-800-237-2515 (TDD
device for the hearing impaired), or write to:
U.S. Department of Justice
Civil Rights Division
Immigrant and Employee Rights Section
950 Pennsylvania Avenue, N.W.
IER, NYA 9000
Washington, DC 20530
For questions about Title VII of the Civil Rights Act of 1964, please contact the Equal Employment Opportunity
Commission by calling 1-800-669-4000 (toll free) or 1-800-669-6820 (TDD device for the hearing impaired).
Form EOIR-58
Revised Date: 05/22/2015

REQUIRED DOCUMENTS (You must include the following in the packet you mail to OCAHO):
1) Original complaint and four additional copies of your completed complaint, each with an original
signature; and
2) Five copies of the charge document (and five copies of any attachments to the charge) you filed with IER;
and
3) Five copies of the letter you received from IER telling you that you may now file your own complaint with
OCAHO.
Except for the original complaint, you should not send the originals of any other documents or attachments to
OCAHO. A copy of the complaint and copies of all attachments will be sent by OCAHO to the Respondent
Business/Employer once the complaint has been filed.

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Section 1: General Information
1) Please provide your name and contact information: Male  Female (circle one)

Full name

(First Name)

(Middle Name)

(Last Name)

Other names used

Street Address

City

State

Home Phone

Cell Number

Email Address

Zip Code

Fax Number

2) When did you file a charge with the Immigrant and Employee Rights Section (IER)?
______/_______/___________
Month

Day

Year

3) When did you receive a letter from IER telling you that you could now file your own complaint
with the Office of the Chief Administrative Hearing Officer (OCAHO)?
______/_______/___________
Month

Day

Year

Section 2: Representation
Do you have an attorney or other authorized representative in this matter? _____YES or _____NO
If YES, please provide the following information:
Name of Representative

Name of Business

Street Address

City

Phone Number

State

Email Address

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Zip Code

Fax Number

Section 3a: Citizenship or Immigration Status at the Time of the Alleged Discrimination
What was your citizenship or immigration status at the time of the alleged discrimination?
 United States Citizen or National or
 Alien Lawfully Admitted for Permanent Residence (“Green Card” Holder) or
 Alien authorized to work in the United States
If you were a United States Citizen at the time of the alleged discrimination, go to Section 4. If
you were not a United States Citizen at the time of the alleged discrimination, please complete
this section.
1) Where were you born (country)?
2) What country were you a citizen of at the time of the alleged discrimination?
__________________________________________
3) If eligible to apply for naturalization, when did you become eligible to apply for naturalization?
(If not yet eligible, leave this answer blank and go to question 5 below.)
/
Month

/
Day

Year

4) Have you applied for naturalization?

YES or

a) If YES, when did you apply?

/
Month

NO
/

Day

Year

5) If you were a permanent resident (i.e., “Green Card” holder) at the time of the alleged
discrimination, when did you obtain your permanent resident status?
/
Month

/
Day

Year

6) If you were otherwise authorized to work in the United States at the time of the alleged
discrimination, what was your citizenship status or visa type (e.g., asylee, refugee, Temporary
Protected Status, H-1B, L-1, F-1, J-1, etc.)?
_________________________________________________________________________
7) What type of work authorization document did you possess at the time of the alleged
discrimination?
_________________________________________________________________________

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Section 3a: Citizenship or Immigration Status at the Time of the Alleged Discrimination Continued
8) For what time period(s) (if any) were you authorized to work in the United States (to the
present)? (If there were breaks in your work authorization, please attach a sheet listing all the
time periods you were authorized to work in the United States.)
From:

/
Month

/
Day

To:
Year

/
Month

/
Day

Year

I have never been authorized to work in the United States: ______

Section 3b: Current Citizenship or Immigration Status Information
What is your current citizenship or immigration status?
 United States Citizen or National or
 Alien Lawfully Admitted for Permanent Residence (“Green Card” Holder) or
 Alien authorized to work in the United States or
 Alien who is not work authorized now, but who was authorized to work in the United
States at the time of the alleged discrimination
If you are a United States Citizen, go to Section 4. If you are not a United States Citizen, please
complete this section.
1) If you are a permanent resident (i.e., “Green Card” holder), when did you obtain your permanent
resident status?
/
Month

/
Day

Year

2) If you are otherwise authorized to work in the United States, what is your citizenship status or
visa type and when did you obtain this status (e.g., asylee, refugee, Temporary Protected Status,
H-1B, L-1, F-1, J-1, etc.)?
_________________________________________________________________________
3) What type of work authorization document do you currently possess?
_________________________________________________________________________
4) For what time period are/were you authorized to work in the United States? (If there were breaks
in your work authorization, please attach a sheet listing all the time periods you were authorized
to work in the United States.)
From:

/
Month

/
Day

To:
Year

/
Month

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/
Day

Year

Section 4: Respondent Business/Employer Information
Please provide the name and contact information for the Business/Employer who allegedly
discriminated against you:
Business/Employer Name

Other names the Business/Employer operates under

Street Address

City

State

Phone

Fax

Zip Code

If you worked at a different location than the Business/Employer address entered above, please identify
the workplace address of the Business/Employer where you worked:

Street Address

City

State

Phone

Fax

Where did the alleged discrimination take place?

Zip Code

_________________________________
City

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State

Section 5: Respondent Business/Employer Representation
If the Business/Employer has an attorney or other representative in this matter, please provide that
information, if known:

Name of Business/Employer Attorney or Representative

Street Address

City

State

Phone

Zip Code
Fax

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Section 6: Basis of Discrimination
1) Were you discriminated against because of your national origin (e.g., where you were born,
foreign language/accent, appearance and/or ancestry, etc.)?
YES or
NO
2) Were you discriminated against because of your citizenship status (e.g., either because you were
or were not a U.S. citizen)?
YES or
NO
3) Were you intimidated, threatened, coerced or retaliated against for exercising your rights under
8 U.S.C. § 1324b?
YES or
NO
4) Were you asked for more or different documents than required for the employment eligibility
verification process (Employment Eligibility Verification Form I-9, electronic employment
eligibility verification “E-Verify” system)?
YES or
NO

Section 7: Discrimination in Hiring, Recruitment, or Referral for a Fee, 8 U.S.C. § 1324b(a)(1)
1) Did the Business/Employer refuse to hire you? ______YES or ______NO
If you answered NO to question (1), go to Section 8. If you answered YES to question (1),
complete the rest of this section.
2) When did you apply for work at the Business/Employer?

/
Month

/
Day

Year

3) Please describe the job title and duties:

4) Were you qualified for the job? ______YES or ______NO
5) Was the Business/Employer looking for workers? ______YES or ______NO
6) Why did the Business/Employer refuse to hire you? (CHECK AS MANY AS APPLY)
 Citizenship status or
 National origin

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Section 7: Discrimination in Hiring, Recruitment, or Referral for a Fee, 8 U.S.C. § 1324b(a)(1)
Continued
7) Please list any other reason(s), if any, why you were not hired:

8) Did the job remain open and the Business/Employer continue taking applications from other
people after you were not hired? ______YES or ______NO
9) Was someone else hired for the job? ______YES or ______NO
10) If you answered YES to question (9) above, to the extent you know, who was hired and why?

11) Do you want to be hired by the Business/Employer? ______YES or ______NO
NOTE: Your answer to question (11) will not affect your right to continue with your
complaint.

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Section 8: Discrimination in Firing, 8 U.S.C. § 1324b(a)(1)
1) Did the Business/Employer fire you? ______YES or ______NO
If you answered NO to question (1), go to Section 9. If you answered YES to question (1),
complete the rest of this section.
2) When were you fired?

/
Month

/
Day

Year

3) Why were you fired? (CHECK AS MANY AS APPLY)
 Citizenship status or
 National origin
4) Please list any other reason(s), if any, why you were fired:

5) Were you fired even though you were qualified for the job? ______YES or ______NO
6) Did other workers with different nationalities or citizenship who were in your (or similar)
position continue working at the Business/Employer? ______YES or ______NO
7) Do you want to be rehired by the Business/Employer? ______YES or ______NO
NOTE: The answer to question (7) will not affect your right to continue with your complaint.

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Section 9: Intimidated, Threatened, Coerced or Retaliated Against, 8 U.S.C. § 1324b(a)(5)
1) Were you intimidated, threatened, coerced, or retaliated against because you filed or planned
to file a complaint? ______YES or ______NO
2) Were you intimidated, threatened, coerced, or retaliated against because you helped or tried to
help someone who filed or planned to file an unfair immigration-related employment practices
complaint? ______YES or ______NO
3) Were you intimidated, threatened, coerced, or retaliated against to keep you from testifying,
assisting, or participating in any manner in an unfair immigration-related employment practices
investigation, proceeding, or hearing?
______YES or ______NO
4) Were you intimidated, threatened, coerced, or retaliated against because you otherwise asserted
your legal rights against unfair immigration-related employment practices?
______YES or ______NO
5) Were you intimidated, threatened, coerced, or retaliated against because you helped someone
assert their legal rights against unfair immigration-related employment practices?
______YES or ______NO
If you answered NO to questions (1), (2), (3), (4), and (5), go to Section 10. If you answered YES to
any of the above questions (1), (2), (3), (4), or (5), please complete this section.
6) Please explain in detail what happened and how you were intimidated, threatened, coerced, or
retaliated against and why (if more space is needed, you may attach a separate sheet(s)
explaining what happened. Please print or type. Please number any additional sheets).

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Section 10: Documentation Practices, 8 U.S.C. § 1324b(a)(6)
1) Did the Business/Employer reject or refuse to accept the documents you presented to prove your
identity and/or show that you are authorized to work in the United States? ______YES or
______NO
If you answered NO to question (1), go to question (3).
2) Please list the documents that the Business/Employer rejected or refused to accept and, to the
extent you know, state why:

3) Did the Business/Employer ask you for more or different documents than required for the
employment eligibility verification process (or the Form I-9or E-Verify system) to show you are
eligible to work in the United States? ______YES or ______NO
If you answered NO to question (3), go to Section 11.
4) If so, please list the documents that the Business/Employer requested and, if applicable, include
the reason the employer gave for requesting these documents:

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Section 11: Relief Requested, 8 U.S.C. § 1324b(g)(2)(B)
The remedies listed below may be available to you. Please check YES or NO for EACH question.
1) Are you seeking back pay (wages you lost because of the Business’/Employer’s alleged actions)?
______YES or ______NO
a) If YES, from what date are you seeking back pay?

/
Month

/
Day

Year

2) Do you want to be rehired? ______YES or ______NO
3) If there is a false performance review or false warning document in your personnel file, would
you like it removed? ______YES or ______NO
4) Are there restrictions on and/or changes to your work assignments, work shifts, or movements
that you would like removed? ______YES or ______NO

Section 12: Declaration and Signature
YOU MUST SIGN AND DATE THE COMPLAINT BELOW.
I declare under penalty of perjury that the foregoing information provided on this form is true and
correct. I respectfully request that OCAHO serve the Complaint and Notice of Case Assignment on the
Respondent and assign an Administrative Law Judge (ALJ) to consider the complaint and to preside at a
hearing as soon as practicable. I also respectfully request that the ALJ grant the relief available to me
under the law, as specified in section 68.52 of Title 28 of the Code of Federal Regulations.
SIGNATURE:
DATE:

REMEMBER, you must send:
 Original complaint and four additional copies of your completed complaint, each with an
original signature; and
 Five copies of the charge document (and five copies of any attachments to the charge) you filed
with IER; and
 Five copies of the letter you received from IER informing you that you may now file your own
complaint with OCAHO.

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PLEASE RETURN TO:
United States Department of Justice
Executive Office for Immigration Review
Office of the Chief Administrative Hearing Officer
5107 Leesburg Pike, Suite 2519
Falls Church, VA 22041

Privacy Act Statement
The authority for requesting this information from the individual or entity is contained in 8 U.S.C. §
1324b and 28 C.F.R. part 68 (Rules of Practice and Procedure for Administrative Hearings Before
Administrative Law Judges in Cases Involving Allegations of Unlawful Employment of Aliens, Unfair
Immigration-Related Employment Practices, and Document Fraud). The information that the individual
or entity provides on this form will be used to initiate and conduct a case before the Office of the Chief
Administrative Hearing Officer under 8 U.S.C. § 1324b. The use of this form is optional. An individual
or entity may elect to provide the information requested herein in an alternative format that complies
with the requirements of 28 C.F.R. part 68.

Paperwork Reduction Act Notice
The information requested in this form is sought in accordance with the Paperwork Reduction Act of
1995. The information collected is necessary to enable the Department of Justice to process and
adjudicate complaints of discrimination under 8 U.S.C. § 1324b, as required by statute. The use of this
complaint form (collection instrument) will facilitate this process by assisting complainants to provide
the information necessary to initiate a proceeding.
The estimated average time burden associated with this collection is 30 minutes per complainant or
his/her representative, depending on individual circumstances. Comments concerning the accuracy of
this burden estimate and suggestions for reducing this burden should be directed to the Executive Office
for Immigration Review, Office of the General Counsel, 5107 Leesburg Pike, Suite 2600, Falls Church,
Virginia, 22041.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.

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