IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO DIVISION __________________________________________________ (Enter Above the Name of the Plaintiff in this Action) vs. __________________________________________________ (Enter above the name of the Defendant in this Action) If there are additional Defendants, please list them: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ COMPLAINT I. Parties to the action: Plaintiff: Place your name and address on the lines below. The address you give must be the address where the court may contact you and mail documents to you. A telephone number is required. _____________________________________________________________________________ Name - Full Name Please - PRINT _____________________________________________________________________________ Street Address _____________________________________________________________________________ City, State and Zip Code _____________________________________________________________________________ Telephone Number If there are additional Plaintiffs in this suit, a separate piece of paper should be attached immediately behind this page with their full names, addresses and telephone numbers. If there are no other Plaintiffs, continue with this form. American LegalNet, Inc. www.FormsWorkFlow.com Defendant(s): Place the name and address of each Defendant you listed in the caption on the first page of this Complaint. This form is invalid unless each Defendant appears with full address for proper service. 1. __________________________________________________________________________________ Name - Full Name Please __________________________________________________________________________________ Address: Street, City, State and Zip Code 2. __________________________________________________________________________________ __________________________________________________________________________________ 3. __________________________________________________________________________________ __________________________________________________________________________________ 4. __________________________________________________________________________________ __________________________________________________________________________________ 5. __________________________________________________________________________________ __________________________________________________________________________________ 6. __________________________________________________________________________________ __________________________________________________________________________________ If there are additional Defendants, please list their names and addresses on a separate sheet of paper. II. Subject Matter Jurisdiction Check the box or boxes that describes your lawsuit: G Title 28 U.S.C. § 1343(3) [A civil rights lawsuit alleging that Defendant(s) acting under color of State law, deprived you of a right secured by federal law or the Constitution.] Title 28 U.S.C. § 1331 [A lawsuit "arising under the Constitution, laws, or treaties of the United States."] Title 28 U.S.C. § 1332(a)(1) [A lawsuit between citizens of different states where the matter in controversy exceeds $75,000.] Title _____ United States Code, Section _______ [Other federal status giving the court subject matter jurisdiction.] G G G -2- American LegalNet, Inc. www.FormsWorkFlow.com III. Statement of Claim Please write as briefly as possible the facts of your case. Describe how each Defendant is involved. Include the name of all persons involved, give dates and places. Number each claim separately. Use as much space as you need. You are not limited to the papers we give you. Attach extra sheets that deal with your statement claim immediately behind this piece of paper. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ -3American LegalNet, Inc. www.FormsWorkFlow.com IV. Previous lawsuits: If you have been a Plaintiff in a lawsuit, for each lawsuit state the case number and caption. (Example, Case Number: 2:08-cv-728 and Caption: John Smith vs. Jane Doe). Case Number Caption vs. vs. vs. V. Relief In this section please state (write) briefly exactly what you want the court to do for you. Make no legal argument, cite no case or statutes. _________________________________________