, , L - P~o Se•:j fRev. 12/16) Complaint for a Civil Case 

UNITED STATES DISTRICT COURT 

for the 

____ District of f\J...,,_. \;,.,,. ,_ :, k ..., 

____ Division 

) 

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Plaintiff(s) ) 

) 

) 

(Write the full name of each plaintiff who is filing this complaint. 

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

please write "see attached" in the space and attach an additional 

page with the full list of names.) ) 

S".J,F'~·h μ ... (\ ip._-,~ c.~...,1 ~;-,,(.'.,_,5-t.i. J""-l,-.~) 

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-P~ ,___\ c..--f•t o.._..;.~ \......rl ~-~~) :V-..t~~ &,,. • t.., .. -.. -.,.r-~ ,..,...,,::i.-.n t;,>- - 'J'> ) 

·P"'a-c, G--~ S::L ~ f+:: ) / Defendant(s) 

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

names of all the defendants cannot fit in the space above, please ) 

write "see attached" in the space and attach an additional page ) 

with the full list of names.) 

Case No. 

(to be filled in by the Clerk's Office) 

Jury Trial: (check one) D Yes rn_No 

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 

needed. 

Name 

Street Address 

City and County 

State and Zip Code 

Telephone Number 

E-mail Address 

B. . The Defendant(s) 

fl>-, ... Q..._v: ✓ C (/-f,,,,(:__j--/:wsfc) 

flt. °J:. 5--t', 

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

individual, a government agency, an organization, or a corporation. For an individual defendant, 

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

Page I of 5 

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

Defendant No. 1 

Name 

Job or Title (ifknown)f~ 

11

t--.{ -~ ::i- ;, 'f:. r k 

Street Address ~ 

City and County -1:::-_V""-__ --~----7-·· -?-~ ~__J-~~--__ -~ 

State and Zip Code 

Telephone Number 

E-mail Address (if known) 

Defendant No. 2 

Name 

Job or Title (if known) 

Street Address 

City and County 

State and Zip Code 

Telephone Number 

E-mail Address (if known) 

Defendant No. 3 

Name 

Job or Title (if !mown) 

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 (if known) 

Page 2-of 5' 

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

II. Basis for Jurisdiction 

Federal courts are courts of limited jurisdiction (limited power). Generally, 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. 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 th_an $75,000 is a diversity ofdtizenshjp_ case. Ji:i a_ 

diversity ,of ~iti~enship 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) 

[2gFederal question D 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 

I. The Plaintiff(s) 

a. If the plaintiff is an individual 

The plaintiff, (name) 

State of (name) 

b. If the plaintiff is a corporation 

The plaintiff, (name) ---------------- under the laws of the State of (name) 

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

, is a citizen of the 

, is incorporated 

(If more than one plaintiff 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) , is a citizen of 

the State of (name) 

(foreign nation) 

----------------0 r is a citizen of 

8:23-cv-00221-JFB-PRSE Doc # 1 Filed: 05/25/23 Page 3 of 5 - Page ID # 3
Pro Se I (Rev. 12/16) Complaint for a Civil Case 

b. If the defendant is a corporation 'f L. c.,, 

The defendant, (name) [ e,-v,.._s ,,._ ?)?a""- μ"'-A~ 2 , is incorporated under 

the laws of the State of (name) N "'U k _ ...,.. ., I,_...._ , and has its 

principal place of business in the State of (name) f'1-,d.,..,,r- ~ k...._ __,__ __ ::..____:_-=--------~-

O r is incorporated under the laws of (foreign nation) 

and has its principal place of business in (name) . . 

l /,_ 'P F ,..J.,.. . ( ~---=,:..-· _____:_· ~~i;-t ~...::____:_____:___ 

. . o{ ~ - ' .,,...,.__-e ::S(Y""' . ~ ,~ ~ \ P--.,.p--e . . .. . . . . . (If more than one defendant is named in the complaint, attach an additional page providing the 

same iriformation 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 possibte'.the 

facts showi11g 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 harm or violated the plaintiffs rights, including 

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

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

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IV. Relief 

State briefly and precisely what damages· or other relief the plaintiff asks the cou1t 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 damages. 

... :' 

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

V. 

Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my knowledge, information, 

and belief that thi.s complaint: (1) is not being presented for an improper purpose, such as to harass, -caus-e -

unnecessary delay, or needlessly increase the cost oflitigation; (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 fmther investigation or discovery; and (4) the complaint otherwise complies with the 

requirements of Rule 11. 

A. For Parties Without an Attorney 

B. 

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 Qffic_e may result 

in the dismissal of my case. 

Date of signing: 

Signature of Plaintiff 

Printed Name of Plaintiff 

For Attorneys 

Date of signing: 

Signature of Attorney 

Printed Name of Attorney 

Bar Number 

Name of Law Firm 

Street Address 

State and Zip Code 

Telephone Number 

E-mail Address 

Page 5 of 5 

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