FILED 3 SEP '1510:1flfJSDC~P 

UNITED STATES DISTRICT COURT 

DISTRICT OF OREGON 

PORTLAND DMSION 

(to be assigned by Clerk of the Court} 

(Enter full name of p/aintiff(s)) 

COMPLAINT 

Plaintiff( s ), 

v. 

Jury Trial De~ed 

0Yes ~No 

(Entu full ~m' of ~r±i Defendant(s). 

I. PARTIES 

List your name, address, and telephone number below, and the same information for each 

defendant. Make sure that the defendant(s) listed below are identical to those contained in the 

caption of the complaint. Attach additional sheets of paper if necessary. 

Plaintiff 

COMPLAINT 

Revised: July 20, 2010 

Name: ~~~-=.r::;;,;.::......r.....:.,_~loC..::;,.,!..,..=--_,;_-.l-~~~~-

Street Address: ..Q,{. 

City, State & Zip Code: _.,_=()~L..C;...;::...........;;--'71.__,,....=----..:.___.. 1 ~ {) (._ 

Telephone No. __..~~0 __ ..3""--___..........__.___..__..J<--....._ __ 

Page I 

Case 3:15-cv-01666-SI Document 2 Filed 09/03/15 Page 1 of 5
Defendant No. 1 

Defendant No. 2 

Defendant No. 3 

Defendant No. 4 

Street Address: -L..Jc........:.~....:..._~=:....~::...._--1---=----'-..L...!~ 

City, State & Zip Code: ..L-.=....--'-L_:;_-=-..:..-=--...L----=-.L.-.:.__ 

Telephone No. _6'.-=--IJ.____.;;:;i,:3_----==......c..--="------L.--'-"<;......;_.;.___ 

Street Address: --------------~ 

City, State & Zip Code: ------------

Telephone No. 

Street Address: ---------------- City, State & Zip Code: ------------

Telephone No. 

II. JURISDICTION 

Federal courts are courts of limited jurisdiction. Only two types of cases can be heard in 

federal court: cases involving a federal question and cases involving diversity of citizenship of the 

parties. A case involving the United States Constitution or federal laws or treaties is a federal 

question case. A case in which a citizen of one state sues a citizen of another state and the amount 

in damages claimed is more than $75,000 is a diversity of citizenship case. 

A. What is the basis for federal court jurisdiction (check all that apply) 

~ederal Question D Diversity of Citizenship 

COMPLAINT Page 2 

Revised: July 20, 20 l 0 

Case 3:15-cv-01666-SI Document 2 Filed 09/03/15 Page 2 of 5
B. If the basis for jurisdiction is Federal Question, what federal Constitutional, statutory, or 

treaty right is at issue? 

C. If the basis for jurisdiction is Diversity of Citizenship, what is the state of citizenship of each 

party? 

Plaintiff(s) state of citizenship ___________________ _ 

Defendant(s) state(s) of citizenship _________________ _ 

Ill. STATEMENT OF CLAIMS 

Claim I 

State here as briefly as possible the facts of your case. Describe how each defendant was 

involved, when the conduct occu"ed, and any injuries you have suffered as a result. It is not 

necessary to give any legal arguments or cite any cases or statutes. 

COMPLAINT Page 3 

Revised: July 20, 20 I 0 

Case 3:15-cv-01666-SI Document 2 Filed 09/03/15 Page 3 of 5
Claim II 

State here as briefly as possible the (acts of your case. Describe how each defendant was 

involved, when the conduct occurred, and any injuries you have suffered as a result. It is not 

necessary to give any legal arguments or cite any cases or statutes. 

/..!; 

/..:2 &fltlj 

State here as briefly as possible the (acts of your case. Describe how each defendant 

was involved, when the conduct occurred, and any injuries you have suffered as a result. It is not 

necessary to give any legal arguments or cite any cases or statutes. 

(If you have additional claims, describe them on another piece of paper, using the same oudine.) 

COMPLAINT Page 4 

Revised: July 20, 2010 

Case 3:15-cv-01666-SI Document 2 Filed 09/03/15 Page 4 of 5
IV. RELIEF 

State briefly exactly what you want the court to do for you and the amount, if any, of 

monetary compensation you are seeking. Make no legal arguments. Cite no cases or statutes. 

I declare under penalty of perjury that the foregoing is true and correct. 

Signed this __ day of _________ , 20 __ . 

(Signature of Plaintiff(s)) 

COMPLAINT Page 5 

Revised: July 20, 20 I 0 

Case 3:15-cv-01666-SI Document 2 Filed 09/03/15 Page 5 of 5