1 IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS (Enter above the full name of the Plaintiff(s) vs. Name Street and number City State ZipCode (Enter above the full name and address of the Defendant in this action - list the name and address of any additional defendants on the back side of this sheet). ) ) ) ) ) ) ) ) Case Number ) ) ) ) ) ) ) CIVIL COMPLAINT I. Parties to this civil action: (In item A below, place your name in the first blank and place your present address in the second blank. Do the same for additional plaintiffs, if any, on the back side of this sheet). A. Name of plaintiff Address American LegalNet, Inc. www.FormsWorkFlow.com 2 (In item B below, write the full name of the defendant in the first blank. In the second blank, write the official position of the defendant. Use item C for the names and positions of any additional defendants). B. Defendantis employed at C. Additional Defendants II. Jurisdiction: (Complete one or more of the following subparagraphs, A., B.1, B.2., or B.3., whichever is applicable.) A. (If Applicable) Diversity of citizenship and amount: 1. Plaintiff is a citizen of the State of . 2. The first-named defendant above is either a. a citizen of the State of ; or b. a corporation incorporated under the laws of the State of and having its principal place of business in a State other than the State of which plaintiff is a citizen. 3. The second-named defendant above is either a. a citizen of the State of ; or b. a corporation incorporated under the laws of the State of and having its principal place of business in a State other than the State of which plaintiff is a citizen. (If there are more than two defendants, set forth the foregoing information for each additional defendant on a separate page and attach it to this complaint.) Plaintiff states that the matter in controversy exceeds, exclusive of interest and costs, the sum of seventy-five thousand dollars ($75,000.00). American LegalNet, Inc. www.FormsWorkFlow.com 3 B. (If applicable) Jurisdiction founded on grounds other than diversity (Check any of the following which apply to this case). 1. This case arises under the following section of the Constitution of the United States or statute of the United States (28 U.S.C. '1331): Constitution, Article, Section; Statute, US Code, Title, Section. 2. This case arises because of violation of the civil or equal rights, privileges, or immunities accorded to citizens of, or persons within the jurisdiction of, the United States (28 U.S.C. '1343). 3. Other grounds (specify and state any statute which gives rise to such grounds): III. Statement of Claim: (State here a short and plain statement of the claim showing that plaintiff is entitled to relief. State what each defendant did that violated the right(s) of the plaintiff, including dates and places of such conduct by the defendant(s). Do not set forth legal arguments. If you intend to allege more than one claim, number and set forth each claim in a separate paragraph. Attach an additional sheet, if necessary, to set forth a short and plain statement of the claim[s].) IV. Relief: (State briefly exactly what judgement or relief you want from the Court. Do not make legal arguments.) American LegalNet, Inc. www.FormsWorkFlow.com 4 V. Do you claim the wrongs alleged in your complaint are continuing to occur at the present time? Yes [ ] No [ ] VI. Do you claim actual damages for the acts alleged in your complaint? Yes [ ] No [ ] VII. Do you claim punitive monetary damages? Yes [ ] No [ ] If you answered yes, state the amounts claimed and the reasons you claim you are entitled to recover money damages. American LegalNet, Inc. www.FormsWorkFlow.com 5 VIII. Administrative Procedures: A. Have the claims which you make in this civil action been presented through any type of Administrative Procedure within any government agency? Yes [ ] No [ ] B. If you answered yes, give the date your claims were presented, how they were presented, and the result of that procedure: C. If you answered no, give the reasons, if any, why the claims made in this action have not been presented through Administrative Procedures: IX. Related Litigation: Please mark the statement that pertains to this case: This cause, or a substantially equivalent complaint, was previously filed in this court as case number and assigned to the Honorable Judge . Neither this cause, nor a substantially equivalent complaint, previously has been filed in this court, and therefore this case may be opened as an original proceeding. Signature of Plaintiff Name (Print or Type) Address American LegalNet, Inc. www.FormsWorkFlow.com 6 City State Zip Code Telephone Number DESIGNATION OF PLACE OF TRIAL Plaintiff designates { [ ]Wichita, [ ]Kansas City , or [ ]Topeka} , Kansas as the (Select One) location for the trial in this matter. Signature of Plaintiff REQUEST FOR TRIAL BY JURY Plaintiff requests trial by jury { [ ]Yes or [ ]No } (Select One) Signature of Plaintiff Dated: (Rev. 10/15) American LegalNet, Inc. www.FormsWorkFlow.com