JS 44 (Rev. 06/17) FLSD Revised 06/01/2017 CIVIL COVER SHEET

The JS 44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as 

provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose 

of initiating the civil docket sheet. (SEE INSTRUCTIONS ON NEXT PAGE OF THIS FORM.) NOTICE: Attorneys MUST Indicate All Re-filed Cases Below.

I. (a) PLAINTIFFS DEFENDANTS

(b) County of Residence of First Listed Plaintiff County of Residence of First Listed Defendant

(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY)

NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE TRACT OF LAND INVOLVED.

(c) Attorneys (Firm Name, Address, and Telephone Number) Attorneys (If Known)

(d)Check County Where Action Arose: MIAMI- DADE MONROE BROWARD PALM BEACH MARTIN ST. LUCIE INDIAN RIVER OKEECHOBEE HIGHLANDS

II. BASIS OF JURISDICTION (Place an “X” in One Box Only) III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an “X” in One Box for Plaintiff)

(For Diversity Cases Only) and One Box for Defendant) 

1 U.S. Government 3 Federal Question PTF DEF PTF DEF

Plaintiff (U.S. Government Not a Party) Citizen of This State 1 1 Incorporated or Principal Place 4 4

of Business In This State

2 U.S. Government 4 Diversity Citizen of Another State 2 2 Incorporated and Principal Place 5 5

Defendant (Indicate Citizenship of Parties in Item III) of Business In Another State

Citizen or Subject of a 3 3 Foreign Nation 6 6

 Foreign Country

IV. NATURE OF SUIT (Place an “X” in One Box Only) Click here for: Nature of Suit Code Descriptions

CONTRACT TORTS FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES

110 Insurance PERSONAL INJURY PERSONAL INJURY 625 Drug Related Seizure 422 Appeal 28 USC 158 375 False Claims Act

120 Marine 310 Airplane 365 Personal Injury - of Property 21 USC 881 423 Withdrawal 376 Qui Tam (31 USC

130 Miller Act 315 Airplane Product Product Liability 690 Other 28 USC 157 3729 (a))

140 Negotiable Instrument Liability 367 Health Care/ 400 State Reapportionment

150 Recovery of Overpayment 320 Assault, Libel & Pharmaceutical PROPERTY RIGHTS 410 Antitrust

& Enforcement of Judgment Slander Personal Injury 820 Copyrights 430 Banks and Banking

151 Medicare Act 330 Federal Employers’ Product Liability 830 Patent 450 Commerce

152 Recovery of Defaulted Liability 368 Asbestos Personal 835 Patent – Abbreviated

New Drug Application 460 Deportation

Student Loans 340 Marine Injury Product 840 Trademark 470 Racketeer Influenced and

(Excl. Veterans) 345 Marine Product Liability LABOR SOCIAL SECURITY Corrupt Organizations

153 Recovery of Overpayment Liability PERSONAL PROPERTY 710 Fair Labor Standards 861 HIA (1395ff) 480 Consumer Credit

of Veteran’s Benefits 350 Motor Vehicle 370 Other Fraud Act 862 Black Lung (923) 490 Cable/Sat TV

160 Stockholders’ Suits 355 Motor Vehicle 371 Truth in Lending 720 Labor/Mgmt. Relations 863 DIWC/DIWW (405(g)) 850 Securities/Commodities/

190 Other Contract Product Liability 380 Other Personal 740 Railway Labor Act 864 SSID Title XVI Exchange

195 Contract Product Liability 360 Other Personal Property Damage 751 Family and Medical 865 RSI (405(g)) 890 Other Statutory Actions

196 Franchise Injury 385 Property Damage Leave Act 891 Agricultural Acts

362 Personal Injury - Product Liability 790 Other Labor Litigation 893 Environmental Matters

Med. Malpractice 791 Empl. Ret. Inc. 895 Freedom of Information

REAL PROPERTY CIVIL RIGHTS PRISONER PETITIONS Security Act FEDERAL TAX SUITS Act

210 Land Condemnation 440 Other Civil Rights Habeas Corpus: 870 Taxes (U.S. Plaintiff 896 Arbitration

220 Foreclosure 441 Voting 463 Alien Detainee or Defendant) 899 Administrative Procedure

230 Rent Lease & Ejectment 442 Employment 510 Motions to Vacate 

Sentence

871 IRS—Third Party 26 

USC 7609 Act/Review or Appeal of

240 Torts to Land 443 Housing/

Accommodations Other: Agency Decision

245 Tort Product Liability 445 Amer. w/Disabilities - 530 General IMMIGRATION 950 Constitutionality of State 

Statutes 

290 All Other Real Property Employment 535 Death Penalty 462 Naturalization Application 

446 Amer. w/Disabilities - 540 Mandamus & Other 465 Other Immigration

Other 550 Civil Rights Actions

448 Education 555 Prison Condition

560 Civil Detainee – Conditions of 

Confinement

V. ORIGIN (Place an “X” in One Box Only)

Transferred from

another district

(specify)

6 Multidistrict

Litigation

Transfer

8 Multidistrict 

Litigation 

– Direct 

File

9 Remanded from 

Appellate Court 

1 Original

Proceeding

2 Removed 

from State 

Court 

3 Re-filed 

(See VI 

below)

4 Reinstated 

or 

Reopened

5 7 Appeal to 

District Judge 

from Magistrate

Judgment

VI. RELATED/

RE-FILED CASE(S)

(See instructions): a) Re-filed Case YES NO b) Related Cases YES NO

 JUDGE: DOCKET NUMBER:

VII. CAUSE OF ACTION

Cite the U.S. Civil Statute under which you are filing and Write a Brief Statement of Cause (Do not cite jurisdictional statutes unless diversity):

LENGTH OF TRIAL via days estimated (for both sides to try entire case)

VIII. REQUESTED IN

 COMPLAINT:

CHECK IF THIS IS A CLASS ACTION

UNDER F.R.C.P. 23 DEMAND $ CHECK YES only if demanded in complaint:

JURY DEMAND: Yes No

ABOVE INFORMATION IS TRUE & CORRECT TO THE BEST OF MY KNOWLEDGE

DATE SIGNATURE OF ATTORNEY OF RECORD

 

FOR OFFICE USE ONLY

RECEIPT # AMOUNT IFP JUDGE MAG JUDGE Amaurys Perez The Goodyear Tire & Rubber Company d/b/a 

Goodyear Commercial Tire & Service Centers Broward County, Florida Summit County, Ohio

R. Martin Saenz, Esq. Saenz & Anderson, PLLC, 20900 NE 30th 

Avenue, #800, Aventura, Fl. 33180

Sherril M. Colombo, Esq. and Chelsea A. Lewis, Esq., Littler 

Mendelson, PC, 333 SE 2nd Avenue, #2700, Miami, Fl. 33131

✔

✔

✘

✔

✔ ✔

28 U.S.C 1331 5

✔

May 12, 2020

Chelsea A. Lewis

Case 0:20-cv-60949-XXXX Document 1-1 Entered on FLSD Docket 05/12/2020 Page 1 of 2
JS 44 (Rev. 06/17) FLSD Revised 06/01/2017

INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS 44

Authority For Civil Cover Sheet

The JS 44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and service of pleading or other papers as 

required by law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is 

required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. Consequently, a civil cover sheet is submitted to the Clerk of 

Court for each civil complaint filed. The attorney filing a case should complete the form as follows:

I. (a) Plaintiffs-Defendants. Enter names (last, first, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency, use 

only the full name or standard abbreviations. If the plaintiff or defendant is an official within a government agency, identify first the agency and then the 

official, giving both name and title.

(b) County of Residence. For each civil case filed, except U.S. plaintiff cases, enter the name of the county where the first listed plaintiff resides at the 

time of filing. In U.S. plaintiff cases, enter the name of the county in which the first listed defendant resides at the time of filing. (NOTE: In land 

condemnation cases, the county of residence of the “defendant” is the location of the tract of land involved.)

(c) Attorneys. Enter the firm name, address, telephone number, and attorney of record. If there are several attorneys, list them on an attachment, 

noting in this section “(see attachment)”.

II. Jurisdiction. The basis of jurisdiction is set forth under Rule 8(a), F.R.C.P., which requires that jurisdictions be shown in pleadings. Place an “X” in 

one of the boxes. If there is more than one basis of jurisdiction, precedence is given in the order shown below.

United States plaintiff. (1) Jurisdiction based on 28 U.S.C. 1345 and 1348. Suits by agencies and officers of the United States are included here.

United States defendant. (2) When the plaintiff is suing the United States, its officers or agencies, place an “X” in this box.

Federal question. (3) This refers to suits under 28 U.S.C. 1331, where jurisdiction arises under the Constitution of the United States, an amendment to the 

Constitution, an act of Congress or a treaty of the United States. In cases where the U.S. is a party, the U.S. plaintiff or defendant code takes precedence, and 

box 1 or 2 should be marked. Diversity of citizenship. (4) This refers to suits under 28 U.S.C. 1332, where parties are citizens of different states. When Box 4 

is checked, the citizenship of the different parties must be checked. (See Section III below; federal question actions take precedence over diversity cases.)

III. Residence (citizenship) of Principal Parties. This section of the JS 44 is to be completed if diversity of citizenship was indicated above. Mark this 

section for each principal party.

IV. Nature of Suit. Nature of Suit. Place an "X" in the appropriate box. If there are multiple nature of suit codes associated with the case, pick the nature 

of suit code that is most applicable. Click here for: Nature of Suit Code Descriptions.

V. Origin. Place an “X” in one of the seven boxes.

Original Proceedings. (1) Cases which originate in the United States district courts.

Removed from State Court. (2) Proceedings initiated in state courts may be removed to the district courts under Title 28 U.S.C., Section 1441. When the 

petition for removal is granted, check this box.

Refiled (3) Attach copy of Order for Dismissal of Previous case. Also complete VI.

Reinstated or Reopened. (4) Check this box for cases reinstated or reopened in the district court. Use the reopening date as the filing date.

Transferred from Another District. (5) For cases transferred under Title 28 U.S.C. Section 1404(a). Do not use this for within district transfers or multidistrict 

litigation transfers.

Multidistrict Litigation. (6) Check this box when a multidistrict case is transferred into the district under authority of Title 28 U.S.C. Section 1407. When this 

box is checked, do not check (5) above.

Appeal to District Judge from Magistrate Judgment. (7) Check this box for an appeal from a magistrate judge’s decision.

Remanded from Appellate Court. (8) Check this box if remanded from Appellate Court. 

VI. Related/Refiled Cases. This section of the JS 44 is used to reference related pending cases or re-filed cases. Insert the docket numbers and the 

corresponding judges name for such cases.

VII. Cause of Action. Report the civil statute directly related to the cause of action and give a brief description of the cause. Do not cite jurisdictional 

statutes unless diversity. Example: U.S. Civil Statute: 47 USC 553

 Brief Description: Unauthorized reception of cable service

VIII. Requested in Complaint. Class Action. Place an “X” in this box if you are filing a class action under Rule 23, F.R.Cv.P.

Demand. In this space enter the dollar amount (in thousands of dollars) being demanded or indicate other demand such as a preliminary injunction.

Jury Demand. Check the appropriate box to indicate whether or not a jury is being demanded.

Date and Attorney Signature. Date and sign the civil cover sheet.

Case 0:20-cv-60949-XXXX Document 1-1 Entered on FLSD Docket 05/12/2020 Page 2 of 2