Pro Se 1 (Rev. 12/16) Complaint for a Civil Case

United States District Court

for the

District of

Division

f o«/ -' J023

CJerk J-S.

fexas Easter, ot

ern

(Write the f ll name of each plainti f who is filing this complaint.

If the name of all the plaintiffs cannot fit in the space above,

please w ite " ee attached" in the spac and attach an additional

page with the full list of name .)

-V-

( rite the full name of each defendant who is being sued. If the

name ofall the defendant cannot fit in the space above, please

write " ee attached" in the pace and attach an additional p ge

with the full li t of ame .)

)

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Case No. ( J

(to be filled in by the Clerk s Office)

Jury Trial: (check one)

COMPLAINT FOR A CIVIL CASE

I. The Parties to This Complaint

A. The Plaintiff(s)

Provide the information below for each plaintiff named in the complaint. Attach additional pages if

Provide the information below for each defendant named in the complaint, whether the defendant is an

individual, gove ment agency, an or anization, or a corpor tion. For an individual defendant,

include the person's job or title (if known). Attach additional pages if needed.

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Pro Se 1 (Rev. 12/16) Complaint for a Civil Case

Defendant No. 1

Name

Job or Title (iflsnown)

Street Address

Citv nd County

State and Zip Code

Telephone Nu ber

E-mail Address (if known) 

Defendant No. 2

Name 

Job or Title (ifknown) 

Street Address 

City and County 

State and Zip Code 

Telephone Number 

E-m il Address (if known) 

Defendant No. 3

Name 

Job or Title (if known)

Street Address 

City and County

State and Zip Code

Telephone Number

E-mail Address (if known)

Defendant No. 4

Name 

Job Or Title (if known)

Street Address 

City and County 

State and Zip Code 

Telephone Number 

E-mail Address (ifknown) 

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II. Basis for Jurisdiction

Federal courts are courts of limited jurisdiction (limited power). Generally, only two types of cases can be

heard in feder l court: cases involving a federal question and cases involving diversity of citizenship of the

parties. Under 28 U.S.C. § 1331, a case arising under the United States Constitution or federal laws or treaties

is a federal question case. Under 28 U.S.C. § 1332, a case in which a citizen of one State sues a citizen of

another State or nation and the amount at stake is more than $75,000 is a diversity of citizenship case. In a

diversity of citizenship case, no defendant may be a citizen of the same State as any plaintiff.

What is the basis for federal court jurisdiction?, (check all that apply)

Federal question Diversity of citizenship

Fill out the paragraphs in this section that apply to this case.

A. If the Basis for Jurisdiction Is a Federal Question

List the specific federal statutes, federal treaties, and/or provisions of the United States Constitution that

are at issue in this case.

B. If the Basis for Jurisdiction Is Diversity of Citizenship

1.

b. If the nlaintiff is a corporation

The plaintiff, ame) , is incorporated

under the laws of the State of (na e) 

and has its principal place of business in the State of (name)

(If more than one plainti f is named in the complaint, attach an additional page providing the

same information for each additional plaintiff)

2. The Defendant(s)

a. If the defendant is an individual

The defendant, (name) 

the State of (name) 

(foreign ation) 

, is a citizen of

Or is a citizen of

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, is incorporated under

, and has its

(If more than one defendant is named in the complaint, attach an additional page providing the

ame information for each additional defendant.)

3. The Amount in Controversy

The amount in controversy-the amount the plaintiff claims the defendant owes or the amount at

stake-is more than $75,000, not counting interest and costs of court, because (explain) .

III. Statement of Claim

Write a short and plain statement of the claim. Do not make legal arguments. State as briefly as possible the

facts showing that each plaintiff is entitled to the damages or other relief sought. State how each defendant was

involved and what each defendant did that caused the plaintiff har or violated the plaintiffs rights, including

the dates and places of that involvement or conduct. If more than one claim is asserted, nu ber each claim and

write a short and plain statement of each claim in a separate paragraph. Attach additional pages if needed.

IV. Relief

State briefly and precisely what damages or other relief the plaintiff asks the court to order. Do not make legal

arguments. Include any basis for claiming that the wrongs alleged are continuing at the present time. Include

the amounts of any actual damages claimed for the acts alleged and the basis for these amounts. Include any

punitive or exemplary damages claimed, the amounts, and the reasons you claim you are entitled to actual or

punitive money damagesa

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CLAIMS FOR RELIEF

FIRST CLAIM FOR RELIEF

Plaintiff re-alleges and incorporate Paragraphs | as if fully

COMPLAINT, page h of, 

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V. Certification and Closing

Under Federal Rule of Civil Procedure 11, by signingbelow, I certify to thebest of my knowledge, information,

and belief that this complaint: (1) is not being resented for an improper purpose, such as to harass, cause

unnecessary delay, or needlessly increase the cost of litigation; (2) is supported by existing law or by a

nonfrivolous argument for extending, modifying, or reversing existing law; (3) the factual contentions have

evidentiary support or, if specifically so identified, will likely have evidentiary support after a reasonable

opportunity for further investig tion or discovery; and (4) the complaint otherwise complies with the

requirements of Rule 11.

A. For Parties Without an Attorney

I agree to provide the Clerk s Office with any changes to my address where case-related papers may be

served, I understand that my failure to keep a current address on file with the Clerk’s Office may result

in the dismissal of my case.

Date of signing: 

B. For Attorneys

Signature of Plaintiff

Printed Name of Plaintiff

Date of si ning: 

Signature of Attorney 

Printed Name of Attorney 

Bar Number

Name of Law Firm

Street Address

State and Zip Code

Telephone Number

E-mail Address

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