Plaintiff or Filing Attorney Information: Name NJ Attorney ID Number Address Telephone Number , Plaintiff, v. Superior Court of New Jersey Division County Part Docket No: (to be filled in by the court) Civil Action , Defendant(s). Complaint Plaintiff, (your name) (your address) , residing at , City of (your city or town) County of (your county) . State Of New Jersey, complaining of defendant, states as follows: 1. On , 20 , (name of person being sued) , Defendant (Summarize what happened that resulted in your claim against the defendant. Use additional pages if necessary.) The defendant in this action resides at (defendant's address) , , State of New Jersey. In the County of (name of county where defendant lives) 2. Plaintiff is entitled to relief from defendant under the above facts. Revised 11/01/2013, CN 11210 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 3. The harm that occurred as a result of defendant's acts include: (list each item of damage and injury) 1. 2. 3. Wherefore, plaintiff requests judgment against defendant for damages, together with attorney's fees, if applicable, costs of suit, and any other relief as the court may deem proper. Dated: Signature: Revised 11/01/2013, CN 11210 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF NO OTHER ACTIONS I certify that the dispute about which I am suing is not the subject of any other action pending in any other court or a pending arbitration proceeding to the best of my knowledge and belief. Also, to the best of my knowledge and belief no other action or arbitration proceeding is contemplated. Further, other than the parties set forth in this complaint, I know of no other parties that should be made a part of this lawsuit. In addition, I recognize my continuing obligation to file and serve on all parties and the court an amended certification if there is a change in the facts stated in this original certification. Dated: Signature: OPTIONAL: If you would like to have a judge decide your case, do not include the following paragraph in your complaint. If you would prefer to have a jury to decide your case, please sign your name after the following paragraph. JURY DEMAND The plaintiff demands trial by a jury on all of the triable issues of this complaint, pursuant to New Jersey Court Rules 1:8-2(b) and 4:35-1(a). Dated: Signature: Revised 11/01/2013, CN 11210 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com