Form EOIR-58 Unfair Immigration-Related Employment Practices Complain

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

GENERAL Instructions

Please read all the instructions carefully. Before you file a complaint with the Office of the Chief Administrative Hearing Officer (OCAHO) under 8 U.S.C. § 1324b, you must have first:

1. Filed a charge with the Immigration 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 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 on this form, you may attach additional sheets. On each additional sheet, please number the sheet and indicate clearly which question(s) you are responding to. If you complete this form by hand, please write using only blue or black ink.

Required Documents:

For complaints filed by mail, you must include the following documents:

1. Original completed complaint form with an original signature; and

2. Four additional copies of your completed complaint, each with an original signature; and

3. Five copies of the charge document (and five copies of any attachments to the charge) you filed with IER; and

4. Five copies of the letter you received from IER telling you that you may now file your own complaint with OCAHO.

For complaints filed electronically, you must include the following documents:

1. Original completed complaint form with an original signature; and

2. One copy of the charge document (and one copy of any attachments to the charge) you filed with IER; and

3. One copy 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.

Filing Documents: The required documents may be electronically filed with OCAHO using the OCAHO Public Access Application, available at https://www.justice.gov/eoir. In limited circumstances, the required documents may be filed by email to CMS.OCAHO@usdoj.gov. The required documents may also be filed with OCAHO by mailing to the following address:

United States Department of Justice
Executive Office for Immigration Review
Office of the Chief Administrative Hearing Officer
5107 Leesburg Pike, Suite 2500
Falls Church, VA 22041

For More Information: If you have any questions about this form, please call OCAHO at 703-305-0864 (Mon.-Fri. 7:00am-4:00pm). If you need to contact IER, please call the IER Worker Hotline at 1-800-255-7688 (toll free) or 1-800-237-2515 (TDD device for the hearing impaired), email IER@usdoj.gov, or write to:

U.S. Department of Justice
Civil Rights Division
Immigrant and Employee Rights Section
950 Pennsylvania Avenue, N.W.
4CON, 7th Floor
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).

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 one (1) hour 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.

Section 1: General Information

1. Sex: ☐ Male ☐ Female

2. Full name (first name, middle name, last name):
   
   

3. Other names used:
   
   

4. Address (street number and name, city, state, zip code):
   
   
   
   

5. Home phone number:
   
   

6. Cell phone number:
   
   

7. Email address:
   
   

8. Fax number:
   
   

9. Date you filed a charge with the Immigration and Employee Rights Section (IER) (MM/DD/YYYY):
   
   

10. Date you received a letter from IER telling you that you could now file your own complaint with the Office of the Chief Administrative Hearing Officer (OCAHO) (MM/DD/YYYY):
    
    
    
    

Section 2: Representation

1. Do you have an attorney or other authorized representative in this matter? ☐ YES or ☐ NO

2. If YES, please provide the following information:

   1. Name of Representative:
      
      

   2. Name of Business:
      
      

   3. Address (street number and name, city, state, zip code):
      
      
      
      

   4. Phone number:

   5. Email address:

   6. Fax number:

Section 3a: Citizenship or Immigration Status at the Time of the Alleged Discrimination

1. 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, please complete this section.

2. Where were you born (country)?
   
   

3. What country were you a citizen of at the time of the alleged discrimination?
   
   

Section 3a: Citizenship or Immigration Status at the Time of the Alleged Discrimination (CONTINUED)

4. 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 card (MM/DD/YYYY)?
   
   

5. If eligible to apply for naturalization, when did you become eligible to apply for naturalization (MM/DD/YYYY)? If not yet eligible, leave this answer blank and go to question 6 below.
   
   

6. Have you applied for naturalization? ☐ YES or ☐ NO

   1. If YES, when did you apply (MM/DD/YYYY)?
      
      

7. 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.)?
   
   
   

8. What type of work authorization document did you possess at the time of the alleged discrimination?
   
   
   

9. 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:            /        /            To:      / /       

Month Day Year Month Day Year

☐ I have never been authorized to work in the United States

Section 3b: Current Citizenship or Immigration Status Information

1. 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.

2. If you are a permanent resident (i.e., “Green Card” holder), when did you obtain your permanent resident status? (MM/DD/YYYY)
   
   

3. 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.)?
   
   
   

4. What type of work authorization document do you currently possess?
   
   
   

5. 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:            /        /            To:      / /       

Month Day Year Month Day Year

Section 4: Respondent Business/Employer Information

1. Please provide the name and contact information for the Business/Employer who allegedly discriminated against you.

   1. Business/Employer Name:
      
      

   2. Other names the Business/Employer operates under:
      
      
      

   3. Address (street number and name, city, state, zip code):
      
      
      
      

   4. Phone number:
      

   5. Fax number:
      
      

2. 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.

   1. Address (street number and number, city, state, zip code):
      
      
      

2. Phone number:
   
   

3. Fax number:
   
   

1. Where did the alleged discrimination take place? (City, State)
   
   

Section 4: Respondent Business/Employer Information (CONTINUED)

4. How many employees does the Business/Employer have?
   ☐ 3 or fewer employees
   ☐ Between 4 and 14 employees
   ☐ 15 or more employees
   ☐ I do not know how many employees the Business/Employer has

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.

1. Name of Business/Employer Attorney or Representative:
   
   
   

2. Address (street number and name, city, state, zip code):
   
   
   
   

3. Phone number:
   
   

4. Fax number:
   
   
   
   

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? (MM/DD/YYYY)
   
   

3. Please describe the job title and duties:
   
   
   
   
   
   

Section 7: Discrimination in Hiring, Recruitment, or Referral for a Fee, 8 U.S.C. § 1324b(a)(1) (CONTINUED)

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

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?
    
    
    
    
    
    

Section 7: Discrimination in Hiring, Recruitment, or Referral for a Fee, 8 U.S.C. § 1324b(a)(1) (CONTINUED)

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.

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? (MM/DD/YYYY)
   
   

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.

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. When did the alleged retaliation occur? (MM/DD/YYYY)
   
   

Section 9: Intimidated, Threatened, Coerced or Retaliated Against, 8 U.S.C. § 1324b(a)(5) (CONTINUED)

7. 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.

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

1. If YES, when did the Business/Employer reject or refuse to accept the documents you presented? (MM/DD/YYYY)
   
   

Section 10: Documentation Practices, 8 U.S.C. § 1324b(a)(6) (CONTINUED)

If you answered NO to question (1), go to question (3). If you answered YES to question (1), answer question (2).

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-9 or E-Verify system) to show you are eligible to work in the United States? ☐ YES or ☐ NO

1. If YES, when did the Business/Employer ask you for more or different documents than required for the employment eligibility verification process? (MM/DD/YYYY)

If you answered NO to question (3), go to Section 11. If you answered YES to question (3), answer question (4).

Section 10: Documentation Practices, 8 U.S.C. § 1324b(a)(6) (CONTINUED)

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:
   
   
   
   
   
   
   
   
   

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

1. If YES, from what date are you seeking back pay? (MM/DD/YYYY)
   
   

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, for complaints filed by MAIL, 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.

PLEASE RETURN MAILED COMPLAINTS TO:

United States Department of Justice

Executive Office for Immigration Review

Office of the Chief Administrative Hearing Officer

5107 Leesburg Pike, Suite 2500

Falls Church, VA 22041

Page 2 of 3 Form EOIR-58
Rev. May 2025
Exp. [date]