FILED24FEB•1613:5'7USDC~ 

UNITED STATES DISTRICT COURT 

DISTRICT OF OREGON 

PORTLAND DIVISION 

Civil Case No.3 .' 16-CV ..-tt'J33J'- Ac. 

{to be assigned by Clerk of the Court} 

(Enter full name of plaintiff(s)) 

COMPLAINT 

Plaintiff(s), 

Jury Trial Demanded 

r ~ D Yes 0No 

>F-1/V,Qcri 1tN5 MSlr Y4h(I e 

(Enter full name of ALL defendant(s)) 

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: 

Telephone No. 

Page 1 

Case 3:16-cv-00338-AC Document 2 Filed 02/24/16 Page 1 of 5
Defendant No. 1 

Defendant No. 2 

Defendant No. 3 

Defendant No. 4 

City, State & Zip Code: 

Telephone No. 

Name: 

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

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

Telephone No. 

Name: 

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) 

~Federal Question D Diversity of Citizenship 

COMPLAINT Page 2 

Revised: July 20, 2010 

Case 3:16-cv-00338-AC Document 2 Filed 02/24/16 Page 2 of 5
B. If the basis for jurisdiction is Federal Question, what federal Cpnstitutional, statutory, or 

__ treaty right is at issue? 51] ~ ~ & C Q ~ tJ> u f\q tJ C. "" I 

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

party? 

Plaintiff(s) state of citizenship __ ____,,L/"---~~/j_~~-------------­ Defendant( s) state( s) of citizenship lJ <) J9 -~-~~~-------------~ 

III. 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 occurred, and any injuries you have suffered as a result. It is not 

necessmy to give any legal s or statutes. 

! 

COMPLAINT Page 3 

Revised: July 20, 20 I 0 

Case 3:16-cv-00338-AC Document 2 Filed 02/24/16 Page 3 of 5
Claim II 

State here as briefly as possible the facts 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 leg 

S6)1 

Claim III 

State here as briefly as possible the facts 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 outline.) 

COMPLAINT 

Revised: July 20, 2010 

Page 4 

Case 3:16-cv-00338-AC Document 2 Filed 02/24/16 Page 4 of 5
IV. RELIEF 

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

etary compensation you are seeking. Make no legal arguments. Ci r ( I 

I declare under penalty of perj th t the foregoing is true and correct. 

Signed this .2!f._ day of~___,..__,~___,."-"-'~ii'+---

COMPLAINT Page 5 

Revised: July 20, 2010 

Case 3:16-cv-00338-AC Document 2 Filed 02/24/16 Page 5 of 5