Revised 03/06 WDNY UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK FORM TO BE USED IN FILING A CIVIL COMPLAINT IN FEDERAL COURT (Non-Prisoner Context) All material filed in this Court is now available via the INTERNET. See Pro Se Privacy Notice for further information. 1. CAPTION OF ACTION A. Full Name of Plaintiff: NOTE: If more than one plaintiff files this action and seeks in forma pauperis status, each plaintiff must submit an in forma pauperis application or the only plaintiff to be considered will be the plaintiff who filed an application. -vsB. Full Name(s) of Defendant(s) NOTE: Pursuant to Fed.R.Civ.P. 10(a), the names of all parties must appear in the caption. The court may not consider a claim against anyone not identified in this section as a defendant. Add a separate sheet, if necessary. 1. 4. 2. 5. 3. 6. 2. STATEMENT OF JURISDICTION, VENUE and NATURE OF SUIT All of these sections MUST be answered Identify the basis for federal Court jurisdiction over your claim, such as that the United States government is a party to the action, all the parties reside in different states and therefore you claim diversity jurisdiction, or the claim presents a federal question or arises under federal law. A. Basis of Jurisdiction in Federal Court: State why the Western District of New York is the proper venue for this action, such as that your claim arises in or the defendant resides in the 17 westernmost counties of New York State. B. Reason for Venue in the Western District: Identify the nature of this action, such as that it is a civil rights claim, a personal injury or personal property (tort) claim, a property rights claim, or whatever it is. C. Nature of Suit: American LegalNet, Inc. www.USCourtForms.com 3. PARTIES TO THIS ACTION PLAINTIFF’S INFORMATION NOTE: To list additional plaintiffs, use this format on another sheet of paper. Name of First Plaintiff: Present Address: Name of Second Plaintiff: Present Address: DEFENDANT’S INFORMATION NOTE: To list additional defendants, use this format on another sheet of paper. Name of First Defendant: Official Position of Defendant (if relevant): Address of Defendant: Name of Second Defendant: Official Position of Defendant (if relevant): Address of Defendant: Name of Third Defendant: Official Position of Defendant (if relevant): Address of Defendant: 4. PREVIOUS LAWSUITS IN STATE AND FEDERAL COURT A. Have you begun any other lawsuits in state or federal court dealing with the same facts involved in this action? Yes No If Yes, complete the next section. NOTE: If you have brought more than one lawsuit dealing with the same facts as this action, use this format to describe the other action(s) on another sheet of paper. 1. Name(s) of the parties to this other lawsuit: Plaintiff(s): 2 American LegalNet, Inc. www.USCourtForms.com Defendant(s): 2. Court (if federal court, name the district; if state court, name the county): 3. Docket or Index Number: 4. Name of Judge to whom case was assigned: 5. The approximate date the action was filed: 6. What was the disposition of the case? Is it still pending? Yes No If not, give the approximate date it was resolved. Disposition (check those statements which apply): _____ Dismissed (check the statement which indicates why it was dismissed): ____ ____ ____ By court sua sponte as frivolous, malicious or for failing to state a claim upon which relief can be granted; By court for failure to prosecute, pay filing fee or otherwise respond to a court order; By court due to your voluntary withdrawal of claim; ____ Judgment upon motion or after trial entered for ____ plaintiff ____ defendant. 5. STATEMENT OF CLAIM Please note that it is not enough to just list the ground(s) for your action. You must include a statement of the facts which you believe support each of your claims. In other words, just tell the story of what happened and do not use legal jargon. Fed.R.Civ.P. 8(a) states that a pleading must contain "a short and plain statement of the claim showing that the pleader is entitled to relief." "The function of pleadings under the Federal Rules is to give fair notice of the claim asserted. Fair notice is that which will enable the adverse party to answer and prepare for trial, allow the application of res judicata, and identify the nature of the case so it may be assigned the proper form of trial." Simmons v. Abruzzo, 49 F.3d 83, 86 (2d Cir. 1995). Fed.R.Civ.P. 10(b) states that “[a]ll averments of claim ... shall be made in numbered paragraphs, the contents of each of which shall be limited as far a practicable to a single set of circumstances.” A. FIRST CLAIM: On (date of the incident) , defendant (give the name and (if relevant) the position held of each defendant involved in this incident) 3 American LegalNet, Inc. www.USCourtForms.com did the following to me (briefly state what each defendant named above did): The federal basis for this claim is: State briefly exactly what you want the Court to do for you. Make no legal arguments and cite no cases or statutes: B. SECOND CLAIM: On (date of the incident) , defendant (give the name and (if relevant) position held of each defendant involved in this incident) did the following to me (briefly state what each defendant named above did): The federal basis for this claim is: State briefly exactly what you want the Court to do for you. Make no legal arguments and cite no cases or statutes: If you have additional claims, use the above format to set them out on additional sheets of paper. 4 American LegalNet, Inc. www.USCourtForms.com 6. SUMMARY OF RELIEF SOUGHT Summarize the relief requested by you in each statement of claim above. Do you want a jury trial? Yes No I declare under penalty of perjury that the foregoing is true and correct. Executed on (date) NOTE: Each plaintiff must sign this complaint and must also sign all subsequent papers filed with the Court. Signature(s) of Plaintiff(s) 5 American LegalNet, Inc. www.USCourtForms.com