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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

IN RE BARD IVC FILTERS

PRODUCTS LIABILITY LITIGATION

No. MD-15-02641-PHX-DGC

AMENDED MASTER SHORT FORM

COMPLAINT FOR DAMAGES FOR

INDIVIDUAL CLAIMS AND DEMAND

FOR JURY TRIAL

Plaintiff(s) named below, for their Complaint against Defendants named below,

incorporate the Master Complaint for Damages in MDL 2641 by reference (Doc. 364).

Plaintiff(s) further show the Court as follows:

1. Plaintiff/Deceased Party:

________________________________________________________________

2. Spousal Plaintiff/Deceased Party’s spouse or other party making loss of

consortium claim:

________________________________________________________________

3. Other Plaintiff and capacity (i.e., administrator, executor, guardian,

conservator):

________________________________________________________________

4. Plaintiff’s/Deceased Party’s state(s) [if more than one Plaintiff] of residence at

the time of implant:

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________________________________________________________________

5. Plaintiff’s/Deceased Party’s state(s) [if more than one Plaintiff] of residence at

the time of injury:

________________________________________________________________

6. Plaintiff’s current state(s) [if more than one Plaintiff] of residence:

________________________________________________________________

7. District Court and Division in which venue would be proper absent direct filing:

________________________________________________________________

8. Defendants (check Defendants against whom Complaint is made):

□ C.R. Bard Inc.

□ Bard Peripheral Vascular, Inc.

9. Basis of Jurisdiction:

□ Diversity of Citizenship

□ Other: ________________________________________________

a. Other allegations of jurisdiction and venue not expressed in Master

Complaint:

________________________________________________________________

________________________________________________________________

________________________________________________________________

10. Defendants’ Inferior Vena Cava Filter(s) about which Plaintiff(s) is making a

claim (Check applicable Inferior Vena Cava Filter(s)):

□ Recovery® Vena Cava Filter

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□ G2® Vena Cava Filter

 G2®Express (G2®X) Vena Cava Filter

 Eclipse® Vena Cava Filter

 Meridian® Vena Cava Filter

 Denali® Vena Cava Filter

 Other: ____________________________________________________

11. Date of Implantation as to each product:

________________________________________________________________

________________________________________________________________

12. Counts in the Master Complaint brought by Plaintiff(s):

□ Count I: Strict Products Liability – Manufacturing Defect

□ Count II: Strict Products Liability – Information Defect (Failure to

Warn)

□ Count III: Strict Products Liability – Design Defect

□ Count IV: Negligence - Design

□ Count V: Negligence - Manufacture

□ Count VI: Negligence – Failure to Recall/Retrofit

□ Count VII: Negligence – Failure to Warn

□ Count VIII: Negligent Misrepresentation

□ Count IX: Negligence Per Se

□ Count X: Breach of Express Warranty

□ Count XI: Breach of Implied Warranty

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□ Count XII: Fraudulent Misrepresentation

□ Count XIII: Fraudulent Concealment

□ Count XIV: Violations of Applicable ________________ (insert state)

Law Prohibiting Consumer Fraud and Unfair and Deceptive Trade

Practices

□ Count XV: Loss of Consortium

□ Count XVI: Wrongful Death

□ Count XVII: Survival

□ Punitive Damages

□ Other(s): ___________________ (please state the facts supporting

this Count in the space immediately below)

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

13. Jury Trial demanded for all issues so triable?

□ Yes

□ No

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RESPECTFULLY SUBMITTED this ____ day of February, 2016.

[SIGNATURE BLOCK]

By: /s/

[Attorney name/address]

I hereby certify that on this ____ day of February, 2016, I electronically transmitted

the attached document to the Clerk’s Office using the CM/ECF System for filing and

transmittal of a Notice of Electronic Filing.

/s/

5220248v1/26997-0001

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