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Form Complaint Form. This is a Ohio form and can be use in Court Of Claims.
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) Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com (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 Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com (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 Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com