(Del. Rev. 11/14) Pro Se General Complaint Form IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE (In the space above enter the full name(s) of the plaintiff(s).) Civ. Action No. (To be assigned by Clerk's Office) -against- COMPLAINT (Pro Se) Jury Demand? Yes No (In the space above enter the full name(s) of the defendant(s). If you cannot fit the names of all of the defendants in the space provided, please write "see attached" in the space above and attach an additional sheet of paper with the full list of names. The names listed in the above caption must be identical to those contained in Section I. Do not include addresses here.) NOTICE Federal Rule of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to electronic court files. Under this rule, papers filed with the court should not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number. A filing may include only: the last four digits of a social security number; the year of an individual's birth; a minor's initials; and the last four digits of a financial account number. If this is an employment discrimination claim or social security claim, please use a different form. Plaintiff need not send exhibits, affidavits, grievance or witness statements, or any other materials to the Clerk's Office with this complaint. Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se General Complaint Form I. PARTIES IN THIS COMPLAINT Plaintiff List your name, address and telephone number. If you are presently in custody, include your identification number and the name and address of your current place of confinement. Do the same for any additional plaintiffs named. Attach additional sheets of paper as necessary. Plaintiff: Name (Last, First, MI) Street Address County, City Telephone Number Defendant(s) State Zip Code E-mail Address (if available) List all defendants. You should state the full name of the defendants, even if that defendant is a government agency, an organization, a corporation, or an individual. Include the address where each defendant can be served. Make sure that the defendant(s) listed below are identical to those contained in the above caption. Attach additional sheets of paper as necessary. Defendant 1: Name (Last, First) Street Address County, City Defendant 2: Name (Last, First) State Zip Code Street Address County, City State Zip Code Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se General Complaint Form Defendant(s) Continued Defendant 3: Name (Last, First) Street Address County, City State Zip Code Defendant 4: Name (Last, First) Street Address County, City II. BASIS FOR JURISDICTION State Zip Code Check the option that best describes the basis for jurisdiction in your case: U.S. Government Defendant: United States or a federal official or agency is a defendant. Diversity of Citizenship: A matter between individual or corporate citizens of different states and the amount in controversy exceeds $75,000. Federal Question: Claim arises under the Constitution, laws or treaties of the United States. If you chose "Federal Question", state which of your federal constitutional or federal statutory rights have been violated. Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se General Complaint Form III. VENUE This court can hear cases arising out of the Counties of New Castle, Kent, and Sussex in the State of Delaware. Under 28 U.S.C § 1391, this is the right court to file your lawsuit if: (1) All defendants live in this state AND at least one of the defendants lives in this district; OR (2) A substantial part of the events you are suing about happened in this district; OR (3) A substantial part of the property that you are suing about is located in this district; OR (4) You are suing the U.S. government or a federal agency or official in their official capacities and you live in this district. Explain why this district court is the proper location to file your lawsuit. Venue is appropriate in this Court because: IV. STATEMENT OF CLAIM Place(s) of occurrence: Date(s) of occurrence: State here briefly the FACTS that support your case. Describe how each defendant was personally involved in the alleged wrongful actions. FACTS: What happened to you? Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se General Complaint Form Was anyone else involved? Page 5 of 8 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se General Complaint Form Who did what? Page 6 of 8 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se General Complaint Form V. INJURIES If you sustained injuries related to the events alleged above, describe them here. VI. RELIEF The relief I want the court to order is: Money damages in the amount of: $ Other (explain): Page 7 of 8 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se General Complaint Form VII. CLOSING Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my knowledge, information, and belief that this complaint: (1) is not being presented for an improper purpose, such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation; (2) is supported by existing law or by a nonfrivolous argument for extending or modifying existing law; and (3) complies with the requirements of Rule 11. 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 Office may result in the dismissal of my case. Dated Plaintiff's Signature Printed Name (Last, First, MI) Address City State Zip Code Telephone Number E-mail Address (if available) List the same information for any additional plaintiffs named. Attach additional sheets of paper as necessary. Plaintiff need not send exhibits, affidavits, grievance or witness statements, or any other materials to the Clerk's Office with this complaint. Page 8 of 8 American LegalNet, Inc. www.FormsWorkFlow.com