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Form Complaint Form. This is a Ohio form and can be use in Court Of Claims.
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Tags: Form Complaint, CC-3, Ohio Court Of Claims,
The Ohio Judicial Center
65 South Front Street, Third Floor
Columbus, OH 43215
614. 387.9800 or 1.800.824.8263
www.cco.state.oh.us
Form Complaint
Case Number
for Court use only
PLAINTIFF:
(1)
plaintiff’s name
(2)
(3)
(4)
(5)
age
street address
city
state
telephone (business)
zip
area code
telephone (home)
area code
NOTE: if you move or change telephone numbers you must give
the Court written notice of the new address or telephone number
DEFENDANT:
(6)
defendant state department, board, commission, etc
(7)
(8)
street address
city
state
zip
The defendant listed in (6) above through its agent(s)
(9)
did on or about
fill in name(s) and title(s) of the agents if known, if unknown state unknown
(10)
fill in date
(11)
state approximate hour
am/pm
(12) Describe in ordinary language the basis of the claim (see instructions)
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(12) Continued
causing plaintiff the following injury, damage or loss (13)
list each item separately
for a total claim of (14)
The witnesses, if any, to the injury, damage or loss are (15)
Fill in name and address
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(16) I (circle the appropriate word or phrase)/have/do not have/insurance coverage for the injury, damage or loss with the
(17)
The policy has a (18)
fill in company name and address and policy number
$
deductible provision.
(19) I (circle the appropriate word or phrase)/have/have not/ received insurance payment(s) in the amount of
(20) $
as a result of the incident described above. (see instructions).
I ask the Court to grant a judgment in the amount stated in blank (14).
If the amount exceeds $2,500.00 the Court may require that a civil rules complaint be filed.
Under the penalties of perjury and falsification, I state that I have read or had read to me the above complaint and
that it is true. Further, I expressly waive, on behalf of myself and of any person who shall have any interest in this
claim, all provisions of law forbidding any physician or other person who has heretofore attended or examined me,
or who may hereafter attend or examine me from disclosing any knowledge or information which they thereby
acquired.
(21)
signature of plaintiff (see instructions)
BE SURE TO INCLUDE FILING FEE AND TO GIVE THE COURT WRITTEN NOTICE OF ADDRESS CHANGES
(see Instructions)
NOTE: Plaintiff need not have an attorney. If plaintiff files the complaint without an attorney, plaintiff completes
Blank (21). If plaintiff files through an attorney, plaintiff signs Blank (21) and the attorney signs Blank (22) and
completes Blanks (23) through (25).
Pursuant to Civil Rule 11, I state I have read the above complaint; that to the best of my knowledge, information,
and belief there is good ground to support it; and that it is not interposed for delay.
(22)
signature of plaintiff’s attorney
(23)
(24)
(25)
street address
city
telephone
state
zip
area code
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