JS44 (Rev.10/20) CIVIL COVER SHEET / , ~<.'1 O / j(J/ &~J 

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.) 

I. (a) PLAINTIFFS DEFENDANTS 

TIMOTHY BAILEY 

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

(EXCEPT IN U.S. PUINTJFF CASES) 

( C) Attorneys (Firm Name, Address, and Telephone Number) 

Shaun Southworth and lanna Richardson 

Southworth PC 

ROBERT WILKIE, SECRETARY, '"',-'"' A r"'l"T"a. .ar- .. l"T" "'r""' \ 1r-,-r-r"'I A a.,,.... A r-r- A''"'" 

County of Residence ofFirst Listed Defendant Palm Beach County 

(IN U.S. PUINTJFF CASES ONLY) 

NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF 

THE TRACT OF LAND INVOLVED. 

Attorneys (I/Known) 

II. BASIS OF JURISDICTION (Place an "X " in One Box Only) m. CITIZENSIIlP OF PRINCIPAL p ARTIES (Place an "X"' in One Box for Plaintiff 

•, U.S. Government 03 Federal Question 

Plaintiff (U.S. Government Not a Party) 

[!] 2 U.S. Government 04 Diversity 

Defendant (Indicate Citizenship of Parties in Item Ill) 

IV. NATURE OF SUIT (Place an "X" in One Box Only) 

CONTRACT TOR'l'S 

§ 110 Insurance 

120 Marine 

130 Miller Act 

140 Negotiable Instrument 

0 150 Recovery of Overpayment 

& Enforcement of Judgment 

0 151 Medicare Act 

0 152 Recovery of Defaulted 

Student Loans 

(Excludes Veterans) 

0 153 Recovery of Overpayment 

of Veteran's Benefits 

0 160 Stockholders' Suits 

0 190 Other Contract 

0 195 Contract Product Liability 

0 196 Franchise 

210 Land Condemnation 

0 220 Foreclosure 

§ 230 Rent Lease & Ejectment 

240 Torts to Land 

245 Tort Product Liability 

0 290 All Other Real Property 

PERSONAL INJURY 

310 Airplane 

315 Airplane Product 

Liability 

320 Assault, Libel & 

Slander 

330 Federal Employers' 

Liability 

340 Marine 

345 Marine Product 

Liability 

350 Motor Vehicle 

Product Liability 

360 Other Personal 

Injury 

362 Personal Injury -

Medical Malpractice 

445 Arner. w/Disabilities -

Employment 

446 Arner. w/Disabilities -

Other 

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

PERSONAL INJURY 

0 365 Personal Injury -

Product Liability 

0 367 Health Care/ 

Pharmaceutical 

Personal Injury 

Product Liability 

0 368 Asbestos Personal 

Injury Product 

Liability 

PERSONAL PROPERTY 

0 370 Other Fraud 

0 3 71 Truth in Lending 

0 380 Other Personal 

Property Damage 

0 385 Property Damage 

Product Liability 

Habeas Corpus: 

463 Alien Detainee 

510 Motions to Vacate 

Sentence 

530 General 

535 Death Penalty 

Other: 

540 Mandamus & Other 

550 Civil Rights 

555 Prison Condition 

560 Civil Detainee -

Conditions of 

Confinement 

(For Diversity Cases Only) and One Box/or Defendant) 

PTF DEF PTF DEF 

Citizen of This State 0 I O Incorporated or Principal Place O 4 0 4 

of Business In This State 

Citizen of Another State 0 2 0 2 Incorporated and Principal Place • 5 05 of Business In Another State 

Citizen or Subject of a 

Foreign Country 

0 3 0 3 Foreign Nation 

625 Drug Related Seizure 

of Property 21 USC 881 

690 Other 

Act 

720 Labor/Management 

Relations 

740 Railway Labor Act 

751 Family and Medical 

Leave Act 

790 Other Labor Litigation 

791 Employee Retirement 

Income Security Act 

Click here for: Nature of Suit Code Descri tions. 

422 Appeal 28 use 158 

423 Withdrawal 

28 USC 157 

870 Taxes (U.S. Plaintiff 

or Defendant) 

871 IRS-Third Party 

26 use 7609 

375 False Claims Act 

376 Qui Tam (31 USC 

3729(a)) 

400 State Reapportionment 

410 Antitrust 

430 Banks and Banking 

450 Commerce 

460 Deportation 

470 Racketeer Influenced and 

Corrupt Organi7.ations 

480 Consumer Credit 

(15'USC 1681 or 1692) 

485 Telephone Consumer 

Protection Act 

490 Cable/Sat TV 

850 Securities/Commodities/ 

Exchange 

890 Other Statutory Actions 

891 Agricultural Acts 

893 Environmental Matters 

895 Freedom of Information 

Act 

896 Arbitration 

899 Administrative Procedure 

Act/Review or Appeal of 

Agency Decision 

950 Constitutionality of 

State Statutes 

0 1 Original D 2 Removed from 

Proceeding State Court 03 Remanded from 

Appellate Court 

D 4 Reinstated or D 5 Transferred from 

Reopened Another District 

(specify) 

D 6 Multidistrict 

Litigation -

Transfer 

D 8 Multidistrict 

Litigation -

Direct File 

Cite the U.S. Civil Statute under which you are filing (Do not cite jurisdictional statutes unless diversity): 

VI. CAUSE OF ACTION Violation of Title VII of the Civil Rights Act of 1964 as amended and Violation of ADEA 

Brief description of cause: 

Discrimination based on sex, age and protected activity. 

VII. REQUESTED IN 

COMPLAINT: 

0 CHECK IF THIS IS A CLASS ACTION 

UNDER RULE 23, F.R.Cv.P. 

VIII. RELATED CASE(S) 

IF ANY (See instructions): 

JUDGE 

DEMANDS CHECK YES only if demanded in complaint: 

JURYDEMAND: 0Yes 0No 

DOCKET NUMBER ----------------- ------------

DATE 

December 21 , 2020 

FOR OFFICE USE ONLY 

RECEIPT# AMOUNT 

SIONA TURE OF ATTORNEY OF RECORD 

APPL YING IFP JUDGE 91 :lHd ll, !:a N\:Jf 

-bcrr-."Htt'"'t-::r"'\-RE'ff-ff371.: 

Case 1:21-cv-00001-MW-GRJ Document 2 Filed 01/05/21 Page 1 of 1