EEOC Form 5 (11/09), Charge of Discrimination Completed Form Examples and Samples

Explore comprehensive examples and samples of a filled EEOC Form 5 (11/09), Charge of Discrimination. Our detailed guides show you how to complete the form for various claims, including age, race, and disability discrimination, with clear narratives and properly filled sections.
EEOC Form 5 (11/09), Charge of Discrimination has a moderate Form Complexity Index of 49/100 — Instafill’s AI completes it in under a minute.
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Completed sample of EEOC Form 5 (Charge of Discrimination) for an age discrimination case.

EEOC Form 5 Sample – Age Discrimination Charge

How this form was filled:

This example shows a completed EEOC Form 5 for an age discrimination claim. It details a scenario where an older employee was terminated and their duties were reassigned to a much younger one. Key sections are filled out, including the charging party's information, the employer's details, the basis for the charge (Age), and a clear narrative of the discriminatory events.

Information used to fill out the document:

  • Charging Party Name: Maria Rodriguez
  • Charging Party Address: 456 Oak Avenue, Anytown, USA 12345
  • Charging Party Phone: 555-123-4567
  • Date of Birth: June 10, 1967
  • Respondent Name (Employer): Global Tech Innovations Inc.
  • Respondent Address: 789 Corporate Blvd, Suite 100, Metropolis, USA 67890
  • Number of Employees: 500+
  • Basis of Discrimination: Age
  • Date of Discrimination (Latest): October 15, 2025
  • Continuing Action: No
  • Charge Narrative: I began my employment with Global Tech Innovations Inc. on March 1, 2005. I consistently received positive performance reviews. On October 15, 2025, I was terminated, with the company citing 'organizational restructuring.' I am 58 years old. My job responsibilities were subsequently assigned to a new hire who is approximately 28 years old and has significantly less experience. I believe I was terminated because of my age in violation of the Age Discrimination in Employment Act (ADEA).
  • Signature Date: January 22, 2026

What this filled form sample shows:

  • Clearly identifies both the Charging Party (employee) and the Respondent (employer).
  • The specific basis for the charge, Age, is correctly checked.
  • Provides a precise date of the discriminatory act (termination date).
  • Includes a concise, factual narrative in the 'Particulars' section, explaining the reason for the belief of discrimination.
  • The form is properly signed and dated, which is required to formally file the charge.

Form specifications and details:

Form Name: EEOC Form 5 (11/09), Charge of Discrimination
Use Case: Filing a charge for age discrimination following a termination.
Categories: discrimination forms, EEOC forms
Created: January 29, 2026 06:56 AM
Completed sample of EEOC Form 5 (Charge of Discrimination) for an age discrimination case.