~tnte of ;Neto Jjer"e1,1

DEPARTMENT OF LA]]OR AND WORKFORCE DEVELOPMENT

JON S. CORZINE PO ]]OX )99 DAVID J. SOCOLOW
Governor TRENTON, NEW JERSEY 08625-0399 AClmg CommissIOner

Dear Sir/Madam:

In response to your recent request, enclosed please find the Complaint of

Discrimination (Form SCF-4) which must be completed and returned in order for us to consider your
complaint of discrimination under the New Jersey Workers' Compensation Law, N.J.S.A. 34:15-39,1,
which states:

It shall be unlawful for any employer or his duly authorized agent to discharge or in any other
manner discriminate against an employee becaase each employee has claimed or attempted to claim workers'
compensation benefits from such employer, or because he has testified, or is about to testify, in a proceeding under this
chapter to which this act is a supplement. For any violation of this act, the employer or agent shall be punished by a
fine of not less that 5100.00 nor more thai 51,000.00, or imprisonment for not more that 60 days or both. Any employee
so discriminated against shall be restored to his employment and shall be compensated by his employer for any loss of
wages arising out of such discrimination; provided, if such employee sholl cease to be qualified to perform the duties of
his employment he shall not be entitled to such restoration and compensation.

If you feel that your diseharge or other employment action meets these eonditions,
and you are currently able to perform the duties of your job, please complete the enclosed
Complaint ofDiscrimination, have it notarized and return it to the address shown above,

Once received, we will investigate your complaint and render a decision, You
will be notified by mail of this decision.

Larry . Crider, Administrator

Special Compensation Funds

ENCLOSURE

.""elY Jersey h An Equal Opporumuy Employer

IWD DIVISION OF WORKERS' COMPENSATION

OFFICE OF SI'ECIAL COMPENSATION fUNDS

Printed on Recycledand RecyclablePaper

S('f.26 (R .1-06)
 ~I'" nf ~.fD :I...OV

Department or Labor and Workforce Development

COMPLAINT OF

Office or Special Compensation Funds

POBox 399
DISCRIMINATION

Trenton, New Jersey 08625-0399

N..J.S.A. J4:1!'i-J9.1 et seq-

The New Jersey Workers' Compensation Low 0.'.J.SA. 34: J5-1 et seq.) provides that it shafl be unlawful for an employer 10 discharge or otherwise
discriminate against an employee because Ihal employee has filed or has attempted /0 file a cloim for workers' compensation benefits or has testified
or has planned to testify ill any proceeding before the Division a/Workers' Compensation. This complaint ts to be completed by on employee who alleges
such discrimination.

01 Your Name, 02 Your Social Security Number:

(1.n.,I) (l'ir,I'f) (M,ddle)

OJ Your complete home address.

(.'>Ireel Number- No 1'0 Boxes) (C'ly) (Counly) (S1(1le) (t,l' C,>de)

04. Your Home Telephone Number 05. If Employed, your Dayume Telephone Number:

06. Nature of Complaint (Ched O"e):

a. 0 I feel thy! I wn discriminated against ben use of my filing or atlrmptlng to file a worker!' cempensatien daim.

b. 0 I fed that I wn diserimiuated agaiMt because of my Intimony or plans to tesury in a workers' compensation proceeding.

07, Name of Employer: 08. New Jersey Employer Identification Number (ifknown)'

09. Complete Employer Address.

(Sll"I'elN"",ber· No PO Boxe,<) (Cily) (C(Jonfy) ';"1(110) (L,l' O>de)

10. Employer Agent Name: II Employer Agent Telephone:

COMPLETE ITEMS #12 THROUGH #20 ONLY IF YOU HAVE CHECKED BOX "a"IN ITEM #06, ABOVE

12. Name of Employer's Workcrs' Compensanou Insurance Carrier 13. Have you flied n claim with this carrier?

0 No CJ Yes, Claim #:

14. Have you filed a Claim with the NJ Dlv. of Workers' Compensation? IS. Dale of Accident/Illness:

0 No 0 Yes. Claim Petition #:

16. Your Occupation ut Time of Accideniqllness. \ 7. Nature of Your Disability:

IS Your Gross Weekly Wages at Time of Accident/lllness­

$ Per Week

19. Your Job Duues at Tmle of Accrdent/lllness:

20 Are You Currently Able to Perform These Duties? (Che,'* One)

0 y" 0 N"

(CONTINUED ON BACK)
SCF--4 (R 7-04)
 (CONTINUED FROM FRONT)

COMPLETE ITEMS 1121 THROVGH 1126 ONLV IF VOl' HAVE CHECKED BOX "b" IN ITE~ #(,

21 Full ~:ltTIe of P.:tilioner in Workers' Compensation Cao;e: 21. Claim Petition Number,

23 Did You Testify in this Case' (C""dOno)

0 No 0 Yes (I(Y.,\. C'wpo'..reIr"", "2~)

" Dale and Location of Testimony.

25. Are You Scheduled 10Teslif)' ,n Ih,s Case? i('I,,,,. (>''''1 26. Scheduled Date and Location ofTestimony.

0 No CI Yes (1/1'"", ('"",pl"f" If"", '2M

27. Dale ofTerminalion or Other Personnel AClion 29. lf Curremly Employed, Employer's Name and Address

28 Reason Give by Employer for Action:

30 If Employed, Your Current Weekly Gross Wages,

s Per Week

JI Stale here and/or on allachcd sheets, the reason(s) for your alleging d,,~rinlillation

Stalt' of New Jersey, County of _

________________________, of full age, being duly sworn according to law. on his/her oath deposes and says:
Thai helshf is the eomplalnant named in the fort'going complaint; that he/she has read the same; and that the matters and lhing therein set forlh
are true affording to (he best of his/her knowledge and bfUef.

Subscribed and sworn before me this _ _ _ dayof • _