UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT COMPLAINT FORM Full name(s) of Plaintiff(s) (Do not use et al.) Case No. ______________________ (To be supplied by the Court) v. Full names of Defendant(s) (Do not use et al.) A. PARTIES 1. ____________________________ is a citizen of _______________________ who (Plaintiff) (State) presently resides at _____________________________________________________. (mailing address) 2. Defendant ___________________________ is a citizen of ___________________ (name of first defendant) (State) whose address is_______________________________________________________. American LegalNet, Inc. www.FormsWorkFlow.com 3. Defendant ____________________________ is a citizen of __________________ (name of second defendant) (State) whose address is ______________________________________________________. (If more space is needed to furnish the above information for additional defendants, continue on a blank sheet which you should label "A. PARTIES." Be sure to include each defendant's identity and complete address.) B. JURISDICTION The jurisdiction of this court is invoked pursuant to: (list statute(s)) _____________________________________________________________________ _____________________________________________________________________ C. NATURE OF THE CASE BRIEFLY state the background of your case. 2 American LegalNet, Inc. www.FormsWorkFlow.com D. CAUSE OF ACTION I allege that the following of my constitutional rights, privileges, or immunities or my rights under a federal statute have been violated and that the following facts form the basis of my allegations: (If more space is needed to explain any allegation or to list additional supporting facts, continue on a blank sheet which you should label "D. CAUSE OF ACTION.") Claim I: __________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Supporting Facts: (Include all facts you consider important, including names of persons involved, places, and dates. Describe exactly how each defendant is involved. State the facts clearly in your own words without citing legal authority or argument.) Claim II: _____________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Supporting Facts: 3 American LegalNet, Inc. www.FormsWorkFlow.com E. REQUEST FOR RELIEF WHEREFORE, plaintiff demands: (state the relief you seek) F. JURY DEMAND Do you wish to have a jury trial? Yes No American LegalNet, Inc. www.FormsWorkFlow.com _____________________________ Original signature of attorney (if any) ______________________________ Printed Name ______________________________ Plaintiff's Original Signature Printed Name () Attorney's full address and telephone () Plaintiff's full address and telephone Email address if available Email address if available DECLARATION UNDER PENALTY OF PERJURY The undersigned declares under penalty of perjury that he/she is the plaintiff in the above action, that he/she has read the above complaint and that the information contained in the complaint is true and correct. 28 U.S.C. § 1746; 18 U.S.C. § 1621. Executed at _________________________ on ________________________. (location) (date) ________________________________ Plaintiff's Original Signature (Rev.3/29/16) 5 American LegalNet, Inc. www.FormsWorkFlow.com