1

IN THE UNITED STATES DISTRICT COURT 

FOR THE SOUTHERN DISTRICT OF OHIO 

EASTERN DIVISION

UNITED STATES OF AMERICA,

 

 Plaintiff,

vs.

BRIDGET M EHRHART-BENNETT

aka BRIDGET M MONTAVON,

 Defendant.

) 

) 

) 

) 

)

)

)

)

)

)

 CASE NO: 2:18-CV-934

COMPLAINT

Now comes the United States of America, by and through its legal representative, the 

United States Attorney for the Southern District of Ohio, and for its cause of action alleges:

1. Jurisdiction is founded on 28 U.S.C. § 1345.

2. Defendant resides within this judicial district and division.

3. On February 26, 2008, defendant submitted an application to the Department of 

Veterans Affairs’ National Nursing Education Initiative (NNEI) for the enrollment period of April 

7, 2008 until March 26, 2010. The Defendant agreed to repay the total of $23,914.00 as set forth 

in said application. A true copy of said application is attached hereto, marked as “Exhibit A”, and 

by this reference made a part hereof.

4. Also, on February 26, 2008, defendant executed and signed a contract with the 

Department of Veterans Affairs’ National Nursing Education Initiative (NNEI). A true copy of 

said contract is attached hereto, marked as “Exhibit B”, and by this reference made a part hereof.

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1 Filed: 08/22/18 Page: 1 of 3 PAGEID #: 1
2

5. On or about October 5, 2010, defendant breached her contact with the Department of 

Veterans Affairs for failure to complete obligated service. In accordance with VHA Handbook 

1020.1, Section D, Paragraph5, “if a participant breaches the agreement by failing for any reason

to complete such participant’s period of obligated service, the United State shall be entitled to 

recover from the participant an amount of triple damages for the amount paid under this 

subchapter, to or on behalf of the participant.” The National Nursing Education Initiative (NNEI) 

awarded and paid on behalf of the defendant, $21,504.00. Pursuant to Section D, paragraph 5 of the 

signed contract (Exhibit A), defendant is obligated to repay the United States $64, 512.00, which is 

triple of said amount. 

6. Although payment has been demanded, payment has not been made by the defendant 

in accordance with the terms of said contract and the entire balance has become due and payable.

7. After all payments on said contract have been properly credited, the entire unpaid

balance due and owing to plaintiff from defendant is $64,512.00 principal, and $5,372.88 interest 

accrued through November 27, 2010, with additional interest accruing on the principal balance 

from said date at the rate of .010 percent per annum, all of which is evidenced by the Certificate 

of Indebtedness which is attached hereto, marked as “Exhibit C” and by this reference made a part 

hereof.

WHEREFORE, plaintiff prays for judgment against defendant in the amount of $64,512.00

principal, and $5,372.88 interest accrued through November 27, 2010, and additional interest on 

the principal balance from said date at the rate of .010 percent per annum to the date of judgment. 

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1 Filed: 08/22/18 Page: 2 of 3 PAGEID #: 2
3

Plaintiff further prays for its costs and for an award of postjudgment interest at the highest 

rate allowable by law, and for all further just and proper orders.

Respectfully submitted,

BENJAMIN C. GLASSMAN

United States Attorney

s/Bethany J. Hamilton

BETHANY J. HAMILTON (0075139)

Assistant United States Attorney

Attorney for Plaintiff

303 Marconi Boulevard, Suite 200

Columbus, Ohio 43215

Office: (614) 469-5715

Fax: (614) 469-5240

E-mail: Bethany.Hamilton@usdoj.gov

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1 Filed: 08/22/18 Page: 3 of 3 PAGEID #: 3
NATIONAL NURSING EDUCATION INITIATIVE (NNEI) APPLICATION

For Nurses Enrolled in or Formally Accepted to an Education or Training Program

NOTE: Priut or type all entries in Sectious I and 2

Section I - General ldentification Informatiou aud Educational History

L Facility Na,ne

Department of Veterans Affairs Medical Center - Chillicothe, Ohio

2. Facility Number

538

last Nalne

Montavon

4. FiNl NaDre

Bridget

5. Middle Initial

M

6. Social Sccurity Numbcr

IXr.Xl- s80s

7. Home Phone (lnclude area code) 8. Work Phooc (lnclude arca c,odc)

VA Employrnchl Status

(ClPck one onlj,) Full{irne

Part-tim.

x

tional Scd.:s Code

0610

itle Codc

50

Assigntnent Codc

88

Re stered Nurse, Nurse Manager

I l. Curnrnt Job Title

l2 Current C,"de Nurse I Nurse ll Nurse lll Nurse lV

Il. Name ofRating Omcial

Cindy Norton-Rousch, MSN, RN

l4 Officiil s Work Phonc (lncluding afta codc)

7 40-7 7 3 -1 I 4 1 extension 7244

15. Highest Degr ec Obhined

lcheck only highest cotnpkled) Associate x

16. Total Nu,nbcr ofSemesler HouN Accumulstcd to Date 2

(Note: To convrt Quat tet' Hours to Semester tlouts, nulliply the nunba of Quarte v Hours by twlhitds)

Section 2 - National Nursirg Education Initiative Enrollment Information

x

17. Dogl.ec SouSht via the NNEI

rcttoc* one atbD

18. Progr"r, Stad Date (MM/DD/YY)

04/0712008

19. Esrimat€d Pmgram Complction Date(MM/DD/YY)

03t26/10

Type ofProgram

(('heck on? onl.v)

The Community-based Family Nurse Practitioner (CFNP) curriculum has a strong academic and clinical basis. In

addition, the CFNP curriculum is unique in providing a strong foundation in understanding the business of primary

care. This includes assessing a community to discover the primary care needs, learning how to develop a plan for

having a fiscally viable practice, and working within the license and insurance regulations of the student's state.

Women's health, including care of the childbearing woman, is a strong component of the program

21. Ptogem Description

22. Name, Address. City, State and Zip Codc of Educationa I lnstilution(s) where aoccplcd or cnlrolled

Altach a copy ofyour Lctter ofAcceptance, ora copy olan ollicial transcripl.

P.O. Box 528, 195 School Street

Hyden, KY 41749

22a. Educational 22b. Addrss ( 1y Stare, Zip) lnstitution Name

Frontier School of Midwifery & Family Nursing (FSMFN)

http://www. m idwives.org

23 Complele the Iollowing ifyou are enrolled in or have becn acccpled to an educalion plograrn that is supPoned by your VISN

23c. Sran Datc

(MM/DD/YY)

23d. End Date

(MM/DD/YY)

+--'tL

) 3a. vlSN/STN No 23b. CouNe Name /orolher i.lenliJicatioD)

GOVERNIIENT

EXHIBIT

a

a

I

I

I

6

fl

{A Department of Veterans Affairs

VA FORM

NOV 1999

10-00031 Page I

t0.

CODES

Bacculaurcale I tu*t". , fr}ther (Specif't))

Master's lOlllet 1Spec1[y,1 

-

f] t traa;tio*l p.gmms consisting ofcurricula oflered in a campus se.tting.

ffi e. Non-fradirional prlgBrrs consisting ofcunicula offered in oli-campus seltings (e.8.. dislancc Ieaming via the Intcmet).

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 1 of 2 PAGEID #: 4
Total Number ofSehester Houfs Required to

(Note: Io convert Quarler HouN to Semester Hours,

nrulliply the number ofQuafter Hours by two{hjrds)

24

Complete Prcgram 57 [] rurr-n,,," I ra t,"

! va ri'n" ! v: r;,"

E Other(Speciry)

2/3 Tine l/4 Time

25 Attendance Schedule (Check one only)

26a - Type of Educational lnstitLrtion 26b - Btimated Tuition Costs 26c -Total Semester Hours Requjred

-fmdilional

Non-Tladilional

20,900.00 55

TOTAL OF COLUN4NS 26h AND 26C

20.900.00 55

26. Esrinate Toral Prcgmm Tujtiofl Costs by TypeofEducation lnstitution

27. &tiDatcd Total Other Reimbursable program Costs 3014.00 (ToraI all non-tuition allowableexpenses)

28. Bti)nated Total Program C;sE

23,914.00 =(Total of26b plus item 27 toral)

29 Averagc Cost per Solester Hour =(Total in Item 28 divided by 26c)

Type of Educarional insritutjon FY 08 FY 09 FYIO FYII FY I]

T,"ditional

Non-Traditionai

1 1584.00 8610.00 3720.00

FY COLUMNS TOTALS

11584.00 8610.00 3120.00

30. Estirnatc Prognrn Fiscal Year (FY) Contracted Educaiton Costs (Note: FY total incl lrdes ali tuition and otherallowable expenses)

(Note: Total mr..rst equal Item 28, Total pro

31. Estirnated Total Prcgrrm Costs

gram Costs)

s23,914.00 =(sum ofall item 30 FY Column Totals)

32. Do have have a Menlof

fi ves INo (tf No, go to ttem 33) Cathy Moore, MSN, RN, BC

32a. Name ofMentor 32b. Title of Meitor

Nurse Educator

EIYES ENO 3 p ta rki n condi ti arrangemenE rcg red 10 uppot yo E 5 afiendance rtq

NP student will llave many hours of clinical time and may need a compressed work schedule during the second year.

33b. lflhe answer to 32a is Yes, briefly descdbe the amangerngnts requircd

33.

Working

Condition

Flexibility

(Check only) YES NO 3l f ngelren !S ra-q uired, ha rhey b mplemented yel? one

CONSENT: I authorize the educational institution in which I am, or witl be, enrolled to release to VA information

\ t'egarding. nty. enrol.l,ment staius and acaderiric standing, including grad point average, both noly and while I am

D 11:tl:ip:tj,g in the VA Emplee ItrcentiYe Schoalrship Program. I understand that tiis authorization is voluntary, 7 and that I may revoke this consent at any time. Howeyer, I further understand that if I voluntarily revoke this authoriTation after the sward of the scholat ship, my scholarship award will be termjnated and I will be liable for the damages in accordance with proyision ofSection 7675, Tifle 3g, United States Code.

S ON 3 - AUTEENTICATI ON en Co to HCSDRO

e/J,, AftJ

lutu (,l Fntt Dalc

J-tu -aa

I hereb tify fo ti

tio ti

C er th I hI ve reVIew this a cation a nd l'ecommend the a cant named a bo pp pp e r part c pa o n

n the Nariona NllrSI EduCL n In tia e Pro ram

/

00

ii gn

Ph L) 1

N C IACH L [,1 ed c2 Cen ter DJ rect 0

Date

j- /.! 'zJ

VA FORI\,,l

NOV 1999 10-00031 Page 2

FY 12

43s.00

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1-1 Filed: 08/22/18 Page: 2 of 2 PAGEID #: 5
NATIoNAL NURSING EDUCA'tIoN INITIATwE (NNED

Ro CONTRACT

INSTRUCTIONST [ro not nrrke e ny altefations to this (locument. Only tlse bflllpohlt pen to complete.

SECTION A - The DepanDrent of Veterarrs Affairs (VA) 6. Notify the Prograrn Coordinator ir writing, of nlty of the

Enrployee Incentive Schotarship Program (EISP) rvas established by following changes within l0 \r,orking days: change in namg

Title Vlll of Poblic Law 105-368 (the "Department of Veterans addrcss, tclephone nunrber, enrollnent status, prcgram ofstudy,

Affairs Health Care Personnel lnceltive Act of 1998'') and codified or acad€rnic standing.

at sections 76'll-7676 ofTitle 38, United States Code. Under lhis

authority, the VA may a\\,ard schotarships urlder they EISP to 7. Ensule lhat the NNEI program officials have access to suppor,heNNEr' i,$:"*I',i;l;1"ffi',il:;rffi,:ffT'::::::'Tn.; il:r:lfi

SECTIoN B - obligations of the Under Secretary for Health. standing, stahls and pmgress ofthe scholarship reciPierll.

Subject to availability of funds appropriated by the Co gress ofthe

United Statcs for the Ernployee Incentiv€ Scholarship Program, the

Under Secretary for Health agrees to:

l. Provide the undersigned employee rvith an I.INEI award

consisting of the payment of tuitiou and reasonable educational

expenses as authorized by 38 U.S.C. $$7671-7675.

2. Ensure that each emp,oyee selected to participate in the NNEI

is an eligible Department enrployee who, as of the date on

rvhich the ernployee subrnits an application for panicipation hr

tho NNEI, has beer continuously employed by the Department

for not less than one year.

3. Appoint the employee to a position plovidiug health services

irr accordance rvith Seclion C9 of lhis conlract. This will be

accomplished as soon as possible after the cnrployee compleres

the NNEI sponsored education or lmining and meets all the

applicable qualification requirenrents for appointnrent lo the

posilion.

SECTION C - Obligation of the Employee. ln consideration of

paynrents nder the NNEI, the enrl>loyee agrees to:

i. Acccpt the NNEI arvard plovided by the Uuder Secretary for

Health undcr Section Bl ofthis conkacl,

2. Purcue edtcation or training in a field leading to appointment

or retention in a Title 38 or Hybrid-Title 38 position listed ir 38

U.S.C., Section 7401 in a health care discipline for rvhich

recruitment or retelttion of qualified personnel is difficult. This

educolion or traini g nlust be approved by the Under Secretary

for Health for parlioipatiol in the NNEI.

3. Maintairr lirll-tirne or parFtilne enrollment until completion

ol tho course of study lor rvhich the scholarship arvard is

provided.

4. Mairtain an acceptable level of acadenric standirg as

detennined by the educational instltution, rvhile enrolled in the

course ofstudy for rvhich the scholarship arvard is provided.

5. Conrplete all courservork rvithin a nraximum of three ),ears

aftct enrollulent for full-time shrdents, and a nraximum of six

years after enrolhrrent for part-tirne students,

9. Serve lhe period of obiigaled s€rvicc by providing hcalth

services in full-time clillical practice ofthe profession for which

lrained or in another health-care posltion iD an assignmGnt and

location in vHA as det€rmiDed by the Under Secretary for

Heslth. The beginning date for the period of obligated service

r.aries depending on the type ofeducation or training receiyed by

the NNEI participant, This is further explaired irl VHA

Handbook 1020.2, National Nursing Education lniative.

'I'he period ofoblig0ted sel'vice for this contract is

SECTION D - Breach of NNEI Arvard. lf a pariicipant:

l. Fails to accept payment or instructs lhe educatiooal instit[tion

to rvhich scholarship paynlents sre to be rnade not to accept

payments under lhis contmct, the participant (othcr than a

participant under parngraph 2 of this section) shall, in addition

to the service or other obligations incurrecl under this contract,

pay to the United States thc srnr of $1,500 0s ,iquidated

dRmages. Paynrent of this amount must be nrade rvithin one

year ofthe date on rvhioh the participant ftils to accept paynrent

of lhe NNEI Scholarship award or hrstructs th€ school not Io

accept paynleIt,

2. Fails to nlaintain an acceptable level of Bcademic standing in

the co rse ofst.rdy for rvhich the auard is provided; is dismissed

frotr lhe educalionffl il)stikrtion for disciplinary reasons;

voluntarily ternlinales the cou rse f slud ot' ro

GOVEBNilENT

EXHIBIT

a

t

2

I

I

-,..) ,.f)

la.!, ueDanmenl ol velerans Aflatrs

f€B 2002 (ns) 10-0003L-4

8. Servs a period of obligated service. All full-titne and

part-time employees who €nroll ill the program must serve a

period of obligated servlce fls full- time employees in thc

Veterans Health Adminislratiorl (VHA). A flrll-linrc student

rvill incur a service obligatlon of three ye8rs, regardless of lhe

arnount of education received under' the NNEI. The obligated

service for a part-limo skrdent is pro-rated. lt is based on the

proportion of tho nunber ofcredit hours carried by the student

in any schooi year to the nurnb* ofcredit hours r€quired to be

carried by a full-tinre student in the approved course of

academic training. Horvever, in no event \rill thc rcquircment

for obligated service under Ihe NNEI be less thao one year or

grcater than three years.

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1-2 Filed: 08/22/18 Page: 1 of 2 PAGEID #: 6
for lvhich the a}lad lyas grantedi fails to become licensed as a

Register Nurse in a State, Territory, Commonlvealth of the

United Stales (i.e., pucrto Rico) or in the Distr.ict of Columhia,

or fails to n)eet any appl,cable licensure requirernent ilt the case of any other health-care persolnel tdro provkle either direct

pa(ienf-care services. or services ilcident to dit€ct patient-carc

sewices, during a period of time determined under regulations

prescribEd.by the Secretary; o1 fails !o nraintain enrprioyment,

rvhile enrolled as a pa(-time studeut in the course of fininirrg

being pursued nnder the NNEI as a Department enployee; thi

l,articipnlt shall, irrstead ol performing tl:e service obiigation

inculred under this contract, repay to the United Srates all"firnds

paid to the parlicipant under this coDtmct. payruent of lhis

anlouot lnust be nlade within one year froln the date academic

lraining teflllinales.

3. BrEach€s the agreen)enl by failing for any reaso lo complele

srrch pa{icipant's period of obligated service, the United Siates

shall be crrtitled {o recover frort lhe par{icipant an antounl

deteimired in accordanc€ lvith the follolvirg fornrula.

A =30 ( t-s / (t) ) in u,hich:

"A" is the amount lhe United States is errlilled lo recover.

"6tr is the surrr of:

(a.) The anlounts paid underlhis subchapter, to or on behalf

of the par.ticipant; 4nd

(b.) Tho iltterest oI such amounts which rvollkl be payable if

at-lhe tille.the auoltnts tvere paid rhey rvere Ioarx teariug

inl"-rcst at the nraxin:rrm legal pr.evailing rate, as rletennined'

by the Trcasurer ofthe Uniled States.

"t" is the total nullrber of nronths in the pa*icipanfs period of

obligated servlce, inctuding,any addirion;l peri;d of iUfigatJ

seNice in accordance $ith Section 7673(cxi), Title 3g, U;ited

States Code.

"s" is the nunrber of nrotrths of sucfi perio<l sorved by the participant ilr accordance with Section 7673, Title:S, UrrltJ

Slates Code.

The anlount the Ullite(l States is eDtitted to recover shall be paicl

rvithin oue year of the datc the Udder Secretary no, HJotti

-deternriles 

that.the parlicipsnt has faited to t .gi,i o. .o,n1ri"i"

lhe.perlod ofobligated service. ,l.he 

amount the Uniled Sfates is

:,l,i,1"1 1" recover rray be offset aga,Dst ,,V .ufo,y, irog"r,

accn,ed leave.or retirernelt annuity rvhich rie partiiipo,,i is

orvcd. at the tinte the participant rvas terDtinated o, fuil.,l to

cortrpiete their. obligated service.

SI4CTION E - Caltcellation, Suspension, ard Waiver ofObligation,

l. Any,sewice or paynleut obligalion incrrrred by a padicipa t

ut)fler thls corllract will be cancelled al the tinre oftheir dealli.

2, The Ul:der Secretary for Heahh may rvaive or suspeud the

padicipanfs servlce or payrnent obligation incurrcd under this

contract if:

a. Conrpliance by the participant ryith the ternrs and

conditions of this contract is in)possible due to

circurnstances beyond th€ control olthe pallicipant, or

b. hr cases not related to paEgraph 2.a., trhen considered in

the best interest of the DeparlrDent of Vcterans Affairs.

Such decisions rvill be nrade by the Under Secrelary for

Heallh on an individual basis.

SECTION F - Consent for Release of lnformation. The

urrdersigned employee consents to allow the educational institution

SECTION C - Ceneml provisions. The Urrtler Secretary for

Health or authorized representative musl accept this contract before

it becomes eff€ctive. Tle regulatiorrs issued by the Under Secretary

for Health to implernent the NNEI are incorpoiated into atld nrarte a

parlofthis contrflct. I agt.ee to conlpty with fllese ragulations.

in rryhich he or.she is enrolled to rclease to the progran] Cooldinator

infounation regading. enrollnent stalus and academic standing

includirrg grade point average at the lime of application and, if

selected, during the period ol arvard partici pation- The applicant

understands that this anthorization is volurtary Bnd the applicant

nuy reyoke the consent at any time. Horvever, the applicant furthet'

understands that iffhis authorizatlon is vohrntarily revoked after the

alYRrd of lhe scholarchip, ths scholarship aryad rvill be ternlinated

and the appl icant rvill be liable for.darnages in accordance u,ith

provrstons oFSection 7675, Title 38, Unites States Code.

APPLICANT'S NAME

nOT E\r.ll*-1 It{cnfoyon

(PLEASE SIGN, DA'fE AND RETURN)

SIGNATURE Oi

HEALTHADMINI

UNDER SECRETARY FOR HEALTH,

STRATION, OR AUTHORIZED REPRESENTATIVE

DAIE

The Program Coofillruttor will

retu t o cot rplele copy tolou,

NATIoNAL NURSING trDUCATIoN INCENTIVE (NNEI) CoNTRACT CoNTINuED

t-lru,-l^rrNLho*,,

APPLICANT'S SIGNATURE

>- >L -d3

DATE

FEA 2O0? (RS) 10-00031-A

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1-2 Filed: 08/22/18 Page: 2 of 2 PAGEID #: 7
AGENCYNAME

CITY AND STATE

Debtor(s) Name(s) and

Address(es) :

Bridget Ehrhart Bennett

SOUTHWEBSTER, OHIO. 45682

$ 98,763.69

I certit, that CHILLICOTFIE VAMC records show that the debtor(s) named above is/are indebted to the United

States in the amount stated above, plus additional interest on the principal balance of $-64112-00_ {iom

0110112010 at the annual rate of 0.01 %. Interest accrues on the principal amount ofthis debt at

the rate of $ 390.79 A MONTH per day.

The claim arose in connection with [Describe with statement such as "a loan made by the NNEI

"a Government-insured or guaranteed loan made by a private lender and assigned to the United States," "a charge by

the NNEI for goods and,/or services," or "an overpayment or erroneous payment by the

NNEI

[Statement of the relevant facts, including: How the debtor(s) became indebted to the United States; the date the

debtor(s) defaulted on the loan, note, or obligation; principal balance ofthe debt; amount and rate ofaccrued interest

on principal balance; additional charges such as penalties and administrative costs; date oflast voluntary payment;

and statutory authorities.l

CERTIFICATION: Pursuant to 28 USC $ 1746, I certi! under penalty ofperjury that the foregoing is true and

correct.

STEPHANIE MCKAY Accountins Tech. Station 538 06/0512018

(Name and Title) (Signature) (Date)

GOVERNTIENT

EXHlBIT

0

CERTIFICATE OF IIIDEBTEDNESS

Total debt due United States as of 0l/01/2010 :

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1-3 Filed: 08/22/18 Page: 1 of 1 PAGEID #: 8
us,K (Re!. r2,o?) cIvIL COVER SHEET

the civil docKeI sheei, (sEE INSTRUCTIoNS oN THE REVERSE oF THE IoRM )

I. (a) PLAt\TIFFS

UNITED STATES OF AI\,IERICA

(b) Counry olResidence ofFtsl Listed Plaintiff

I)Ut UNI)ANt S

Bridget M Ehrhart-Bennett

aka Bridget M Montavon

Counry ofResidence ofFirst Listed Defendant ROSS

(IN U.S, PI-AINTIFF CASES ONLY)

NOTE: IN LAND CONDEMNATION CASES. USE fiE LOCATION OF THE

LAND INVOLVED.

(C) Anome\ s,l m:'lme. AJdrc,\ dd I.lcDhone Ntrmber,

BETHANY J. HAl,4lLTON. Assistant Unrled States Attorney

303 Marconi Boulevard, Suite 200, Columbus, Ohio 43215

II. BASIS OF JURISDICTION (phceo x in one Box onry)

X I U.S. Gole1me O I Fed€ral Quesi'on

Plaintrti (tJ.S Govemmenr Nor a Panvl

III. CITIZENSHIP OF PRINCIPAL PARTIESpbce an'x- ii one Bor ror plainriff

(Fq Divc6iiy C&s Only) and On€ Box for D.fen&no

PTf DEF PTT DET

Chzen ofThis Slar. O I O I Incoryomred dr Principal Plac. O.1 O4

ofBusiness In This Slate

Attomeys (lf KnoM)

Cn,.n or SubJeci ofa Ol O 3 Forcig Ndioo

O 2 U.S. Covenm.nr O 4 DiveBity

(lndi€te Cniaship ofPanics in hcm lll)

Ciiiz., ofAnorher Sore O2 d 2 IncoQcared ard kincipal PIae

ofBurincss In Alorhd S6te

o

o

5 t,5

6 .,6

c()\TR{(_T tl,\\KRt'P't( l'

O 422 Appeal23 USC 158

O 423 wirh&a*

28 USC t57

O 610 AgriclltE

O 620 Oha Food & Drus

al 625 Dru8 Rclat.d S.izir..

ofkop.rty 2l USC 88t

O 630 Lhuor L5*s

O 640 R.R. & Truct

O 650 Airlin. Rcss.

O 660 O.clFtioml

S!f.tyiHcrlft

Cl 690 Orh.r

O 820 Copyrishs

O 810 Pare

O 840 Tr.demark

I \a()R \{x-L{I S}(-t Rt tY

o

o

o

o

o

o

o

PERSONAL INJURY

310 Airplan€

3 15 Anplan€ MBI

Liability

120 Asull Lib.l &

Slader

330 Fed@l Enploy..s'

Liability

Liability

350 Moror v.hicle

355 Morcr vchicle

360 Odler Pclso@l

lnjm,

PEXSONAL INJURY

O 162 Pcrsonal hjury -

M.d. Malpnctic.

O 165 Pdsonal Iniuly -

Producl Liability

O 36E A$.sos PcEonal

lnJuy Product

Liabiliry

PERgONAL PROPERTY

O 170 olh.r Fraud

O 37 I Truth i. LmdinS

O 3E0 Otltc. P.rsonal

Propcrq/ Danase

O 385 Pmp..ty Dmagc

Produ.l Liability

-,]

-,]

o 86r HrA ( | 395ff)

O 862 Black Luns (921)

O E63 DlwcDlww (405(g))

o 864 SS|D Titt. XVI

O 865 RSI {405(e))

CI\IL RIGHI'S PRIS()\|kttIrrr(,\s [}]Dt:R,\l_-I A\ SI]tTS

O 710 Fair Llbor Siald'Ids

O 720 Labo./Mgmt R.htions

O 710 bbor^.lgmrR.poning

& Disclosur€ Acr

O 740 R.il*ay Llbor Acr

O 7$ O$cr Lrbor Lni8arion

O 791 Espl. R.l. I.c.

III\flGRA-tIOl

O ,l4l voritrg

O 442 Employm.nt

O 441Housing/

Ac.ommo&tions

O 444 Welfare

O 445 Amr. w/Disabihies -

Emplotme

d 446 Affi. wDisabilities -

Orher

al 440 Oth6 Cilil Rights

O 510 Morions ro va€i.

O 5locmeml

O 515 D.atl Pemlty

O 540 Mddamus & othcr

O 550Civil tu8hts

O 555 Prison Condition

O 462 Natralizarioo Application

O 461 Hat as Corpus -

O 465 Olh.r ltn nigration

O 870 Tar.s (U.S. PhiDtitr

O 871 IRS Third Paity

25 USC 7609

rfltll lrallr*flr rar

l

I\I. NA 1'

O Il0lnsl'tztre

O 120 Mdine

O ll0MillerAct

O l,rc NeSoiable lnstlmdr

O I J0 Recolery ofoYerya)ment

& Enforcemflr ofludsnen

O l5l Medi€re Acr

O 152 Recolery of Defaulted

(Excl velss)

O 153 Recotery of Ovenayment

of Veierar\ Benefrls

O 160 $@*holde6' suirs

tl l9o odr( Cont r.r

O 195 CoDEacr ttoduct Liability

O 196 Frachis

O 400 Slrl. ReapDonioomor

O 4l0A.dtrusr

O 410 Bank and Banting

O 450 Commace

ar 460 D.ponado

O 470 Pack.ier InflEnccd aid

C(npr OrsdizrioB

O 480 Colsullt.. CEdlt

O 490 Cable,Bar rv

O 810 S.lccdv. Scrlice

d 850 Sdni.Vcommdliri.V

Exchange

O 8?5 Cu$omer Challensc

t2 usc 14l0

O 8m Othcr Sr.lutory ActioE O E9l AgnculunlAds

O E92 Eonmic Slabili?rlion Ac1

O 891 Frviroornenial Maners

O 894 tu€.gy All@tion Act

O 895 FF.dom of Inflmatim

O 9ooAppcal ofF€e DetemDation

Undcr Eaual Ac@$

O 950 Consdnltion.lity of

O 2l0Lmd Condemnon

O 220 Foreclosd.

O 210 Rent Lease & Fjechent

O 240 Ions to Lod

O 2:15 Ton Produd I-!!bili,)-

O 290 All Other Real Prop.rty

(Plae an 'X'in ODe Box Only)

D 2 Renoved from 03 Remanded from O 4 Reinsrated or

State Coun Appellate Court Reopened

o5 Transferred from

another district

Appealro Dirrricl

Judge Iiorn 06 Mulridistricr 0 7

Litigation

Cile thc U.S. Civil Statute undcr which you are lilinS (Do not cite j o risdlcrion r I strtutes untess diYersity)

Brief description of cause

0 cuecr Ir rHrs rs n clAss AcrroN

UNDER F,R.C,P, 23

DE}IAND $ ('HE(lK YES only ifdemanded in complaint

JURY DtrMAND: D Yes O No

VI. CAT]SE OT' ACTION

VII. REQUESTED IN

COMPLAINT:

RECEIPT ri AMOt_r)tl APPI,YING IFP .llIt)cll

v

MAC JUDGE

YIII. RELATED CASE(S)

IF ANY JI]DCIi

NIIY OF RE]CORI)

Assistant U.S. Attorne

IXX'KIJINI]N1I}1:]{

DATE

ioR ()Frl

IUR

(EXCEPT IN U,S, PLAINTIfF CASES)

V. ORIGIN

81 Original

P.oceeding

Case: 2:18-cv-00934-EAS-KAJ Doc #: 1-4 Filed: 08/22/18 Page: 1 of 1 PAGEID #: 9