prose complaint employment - ao 239 (01/09) application to proceed in district court without...

8/7/2019 Prose Complaint Employment - AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or C

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I N S T R U C T I O N S F O R F I L I N G A C I V I L

C A S E I N U . S . D I S T R I C T C O U R T

1 . $ 3 5 0 F i l i n g F e e - u n l e s s y o u a r e G R A N T E D t h e r i g h t t o p r o c e e d

w i t h o u t p r e p a y m e n t o f f e e s . I f y o u a r e D E N I E D t h e r i g h t t o

p r o c e e d w i t h o u t p r e p a y m e n t o f f e e s , y o u w i l l h a v e 3 0 d a y s t o p a yt h e f i l i n g f e e o r y o u r c a s e w i l l b e c o n v e r t e d t o a m i s c e l l a n e o u s

c a s e a n d a u t o m a t i c a l l y d i s m i s s e d b y t h e c o u r t .

2 . C o m p l e t e C i v i l C o v e r S h e e t ( F S - 4 4 ) - 1 c o p y - m u s t b e s i g n e d

& d a t e d

3 . P r e p a r e c o m p l a i n t l i s t i n g y o u r c o m p l e t e a d d r e s s a n d t e l e p h o n e

n u m b e r . Y o u w i l l n e e d a n o r i g i n a l f o r t h e c o u r t , o n e f o r e a c h

d e f e n d a n t a n d a c o p y f o r y o u r f i l e s .

4 . S u b m i t 3 s u m m o n s f o r e a c h d e f e n d a n t - o n e f o r t h e c o u r t , o n e

t o s e r v e w i t h t h e c o m p l a i n t a n d a c o p y t o r e t u r n t o t h e c o u r ta f t e r s e r v i c e h a s b e e n e f f e c t e d .

5 . D i s c l o s u r e o f C o r p o r a t e A f f i l i a t i o n s - a n o r i g i n a l a n d a c o p y

f o r y o u r f i l e s .

P u r s u a n t t o F e d e r a l R u l e s o f C i v i l P r o c e d u r e 5 . 2 , a d d r e s s i n g t h e

p r i v a c y c o n c e r n s c r e a t e d b y i n t e r n e t a c c e s s t o c o u r t d o c u m e n t s ,

u n l e s s o t h e r w i s e o r d e r e d b y t h e c o u r t , t h e f i l i n g p a r t y s h a l l n o t

i n c l u d e p e r s o n a l i n f o r m a t i o n i n p l e a d i n g s a n d o t h e r p a p e r s a s

f o l l o w s :

( a ) S o c i a l S e c u r i t y N u m b e r s . I f a n i n d i v i d u a l s s o c i a l

s e c u r i t y n u m b e r m u s t b e i n c l u d e d i n a d o c u m e n t , o n l y t h e

l a s t f o u r d i g i t s o f t h a t n u m b e r s h a l l b e u s e d .

( b ) N a m e s o f M i n o r C h i l d r e n . I f t h e i n v o l v e m e n t o f a

m i n o r c h i l d m u s t b e m e n t i o n e d , o n l y t h e i n i t i a l s o f

t h a t c h i l d s h a l l b e u s e d .

( c ) D a t e o f B i r t h . I f a n i n d i v i d u a l s d a t e o f b i r t h

m u s t b e i n c l u d e d i n a d o c u m e n t , o n l y t h e y e a r s h a l l

b e u s e d .

( d ) F i n a n c i a l A c c o u n t N u m b e r s . I f f i n a n c i a l a c c o u n t

n u m b e r s a r e r e l e v a n t , o n l y t h e l a s t f o u r d i g i t s o f t h e s e

n u m b e r s s h a l l b e u s e d .

S E R V I C E O F T H E C O M P L A I N T

S e r v i c e o f t h e c o m p l a i n t m a y b e e f f e c t e d b y c e r t i f i e d m a i l ,

r e t u r n r e c e i p t r e q u e s t e d o r b y p e r s o n a l s e r v i c e b y a n y o n e o v e r


2/26

t h e a g e o f e i g h t e e n ( 1 8 ) y e a r s o f a g e w h o i s n o t a p a r t y t o t h e

c a s e . A R e t u r n o f S e r v i c e m u s t b e m a d e t o t h e c o u r t s h o w i n g

p r o o f o f s e r v i c e . T h i s i s a d o c u m e n t t h a t y o u w i l l p r e p a r e

l i s t i n g y o u r c a s e c a p t i o n a n d c a s e n u m b e r a n d a t t a c h i n g t h e g r e e n

r e t u r n r e c e i p t c a r d t o y o u r d o c u m e n t .

S e r v i c e f o r a p p l i c a n t s a p p l y i n g I n F o r m a P a u p e r i s w h o a r e

g r a n t e d t h e r i g h t t o p r o c e e d w i t h o u t p r e p a y m e n t o f f e e s w i l l b e

m a d e b y t h e U n i t e d S t a t e s M a r s h a l S e r v i c e .

A l l f o r m s c a n b e f o u n d o n o u r w e b s i t e a t w w w . n c e d . u s c o u r t s . g o v .


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OJS 44 (Rev. 12/07) CIVIL COVER SHEETThe JS 44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as pr

y local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose of inhe civil docket sheet. (SEE INSTRUCTIONS ON THE REVERSE OF THE FORM.)

. (a) PLAINTIFFS DEFENDANTS

(b) County of Residence of First ListedPlaintiff County of Residence of First Listed Defendant(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY)

NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE

LAND INVOLVED.

(c) Attorneys (Firm Name, Address, and Telephone Number) Attorneys (If Known)

I. BASIS OF JURISDICTION (Place an X in One Box Only) III. CITIZENSHIP OF PRINCIPAL PARTIES(Place an X in One Box for P(For Diversity Cases Only) and One Box for Defendant

1 U.S. Government 3 Federal Question PTF DEF PTF DPlaintiff (U.S. Government Not a Party) Citizen of This State 1 1 Incorporated orPrincipal Place 4

of Business In This State

2 U.S. Government 4 Diversity Citizen of Another State 2 2 Incorporated andPrincipal Place 5

Defendant(Indicate Citizenship of Parties in Item III)

of Business In Another State

Citizen or Subject of a 3 3 Foreign Nation 6

Foreign Country

V. NATURE OF SUIT (Place an X in One Box Only)CONTRACT TORTS FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTE

110 Insurance PERSONAL INJURY PERSONAL INJURY 610 Agriculture 422 Appeal 28 USC 158 400 State Reapportionm

120 Marine 310 Airplane 362 Personal Injury - 620 Other Food & Drug 423 Withdrawal 410 Antitrust

130 Miller Act 315 Airplane Product Med. Malpractice 625 Drug Related Seizure 28 USC 157 430 Banks and Banking

140 Negotiable Instrument Liability 365 Personal Injury - of Property 21 USC 881 450 Commerce

150 Recovery of Overpayment 320 Assault, Libel & Product Liability 630 Liquor Laws PROPERTY RIGHTS 460 Deportation& Enforcement of Judgment Slander 368 Asbestos Personal 640 R.R. & Truck 820 Copyrights 470 Racketeer Influence

151 Medicare Act 330 Federal Employers Injury Product 650 Airline Regs. 830 Patent Corrupt Organizatio

152 Recovery of Defaulted Liability Liability 660 Occupational 840 Trademark 480 Consumer Credit

Student Loans 340 Marine PERSONAL PROPERTY Safety/Health 490 Cable/Sat TV(Excl. Veterans) 345 Marine Product 370 Other Fraud 690 Other 810 Selective Service

153 Recovery of Overpayment Liability 371 Truth in Lending LABOR SOCIAL SECURITY 850 Securities/Commodiof Veterans Benefits 350 Motor Vehicle 380 Other Personal 710 Fair Labor Standards 861 HIA (1395ff) Exchange

160 Stockholders Suits 355 Motor Vehicle Property Damage Act 862 Black Lung (923) 875 Customer Challenge

190 Other Contract Product Liability 385 Property Damage 720 Labor/Mgmt. Relations 863 DIWC/DIWW (405(g)) 12 USC 3410

195 Contract Product Liability 360 Other Personal Product Liability 730 Labor/Mgmt.Reporting 864 SSID Title XVI 890 Other Statutory Acti

196 Franchise Injury & Disclosure Act 865 RSI (405(g)) 891 Agricultural Acts

REAL PROPERTY CIVIL RIGHTS PRISONER PETITIONS 740 Railway Labor Act FEDERAL TAX SUITS 892 Economic Stabilizat

210 Land Condemnation 441 Voting 510 Motions to Vacate 790 Other Labor Litigation 870 Taxes (U.S. Plaintiff 893 Environmental Mat

220 Foreclosure 442 Employment Sentence 791 Empl. Ret. Inc. or Defendant) 894 Energy Allocation A

230 Rent Lease & Ejectment 443 Housing/ Habeas Corpus: Security Act 871 IRSThird Party 895 Freedom of Informa 240 Torts to Land Accommodations 530 General 26 USC 7609 Act

245 Tort Product Liability 444 Welfare 535 Death Penalty IMMIGRATION 900Appeal of Fee Determ 290 All Other Real Property 445 Amer. w/Disabilities - 540 Mandamus & Other 462 Naturalization Application Under Equal Access

Employment 550 Civil Rights 463 Habeas Corpus - to Justice

446 Amer. w/Disabilities - 555 Prison Condition Alien Detainee 950 Constitutionality of

Other 465 Other Immigration State Statutes

440 Other Civil Rights Actions

V. ORIGINTransferred fromanother district(specify)

Appeal to DJudge fromMagistrateJudgment

(Place an X in One Box Only)

1 OriginalProceeding

2 Removed fromState Court

3 Remanded fromAppellate Court

4 Reinstated orReopened

5 6 MultidistrictLitigation

7

VI. CAUSE OF ACTION

Cite the U.S. Civil Statute under which you are filing (Do not cite jurisdictional statutes unless diversity):

Brief description of cause:

VII. REQUESTED INCOMPLAINT:

CHECK IF THIS IS A CLASS ACTIONUNDER F.R.C.P. 23

DEMAND $ CHECK YES only if demanded in complaint

JURY DEMAND: Yes No

VIII. RELATED CASE(S)IF ANY

(See instructions):JUDGE DOCKET NUMBER

DATE SIGNATURE OF ATTORNEY OF RECORD

FOR OFFICE USE ONLY

RECEIPT # AMOUNT APPLYING IFP JUDGE MAG. JUDGE

Print Save As... Export as FDF Retrieve FDF File Reset


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44 Reverse (Rev. 12/07)

INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS 44

Authority For Civil Cover Sheet

The JS 44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and service of pleading or other papers as reqy law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for thf the Clerk of Court for the purpose of initiating the civil docket sheet. Consequently, a civil cover sheet is submitted to the Clerk of Court for each civil comled. The attorney filing a case should complete the form as follows:

(a) Plaintiffs-Defendants. Enter names (last, first, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency, ushe full name or standard abbreviations. If the plaintiff or defendant is an official within a government agency, identify first the agency and then the official, g

oth name and title.

(b) County of Residence. For each civil case filed, except U.S. plaintiff cases, enter the name of the county where the first listed plaintiff resides at thf filing. In U.S. plaintiff cases, enter the name of the county in which the first listed defendant resides at the time of filing. (NOTE: In land condemnation he county of residence of the defendant is the location of the tract of land involved.)

(c) Attorneys. Enter the firm name, address, telephone number, and attorney of record. If there are several attorneys, list them on an attachment, nn this section (see attachment).

I. Jurisdiction. The basis of jurisdiction is set forth under Rule 8(a), F.R.C.P., which requires that jurisdictions be shown in pleadings. Place an X f the boxes. If there is more than one basis of jurisdiction, precedence is given in the order shown below.

United States plaintiff. (1) Jurisdiction based on 28 U.S.C. 1345 and 1348. Suits by agencies and officers of the United States are included here.

United States defendant. (2) When the plaintiff is suing the United States, its officers or agencies, place an X in this box.

ederal question. (3) This refers to suits under 28 U.S.C. 1331, where jurisdiction arises under the Constitution of the United States, an amendment onstitution, an act of Congress or a treaty of the United States. In cases where the U.S. is a party, the U.S. plaintiff or defendant code takes precedence, an

or 2 should be marked.Diversity of citizenship. (4) This refers to suits under 28 U.S.C. 1332, where parties are citizens of different states. When Box 4 is checked, the citizenship

ifferent parties must be checked. (See Section III below; federal question actions take precedence over diversity cases.)

II. Residence (citizenship) of Principal Parties. This section of the JS 44 is to be completed if diversity of citizenship was indicated above. Mark this sor each principal party.

V. Nature of Suit. Place an X in the appropriate box. If the nature of suit cannot be determined, be sure the cause of action, in Section VI below, is suffo enable the deputy clerk or the statistical clerks in the Administrative Office to determine the nature of suit. If the cause fits more than one nature of suit, he most definitive.

V. Origin. Place an X in one of the seven boxes.

Original Proceedings. (1) Cases which originate in the United States district courts.

emoved from State Court. (2) Proceedings initiated in state courts may be removed to the district courts under Title 28 U.S.C., Section 1441. When the peor removal is granted, check this box.

emanded from Appellate Court. (3) Check this box for cases remanded to the district court for further action. Use the date of remand as the filing date.einstated or Reopened. (4) Check this box for cases reinstated or reopened in the district court. Use the reopening date as the filing date.

ransferred from Another District. (5) For cases transferred under Title 28 U.S.C. Section 1404(a). Do not use this for within district transfers or multidtigation transfers.

Multidistrict Litigation. (6) Check this box when a multidistrict case is transferred into the district under authority of Title 28 U.S.C. Section 1407. When thchecked, do not check (5) above.

Appeal to District Judge from Magistrate Judgment. (7) Check this box for an appeal from a magistrate judges decision.

VI. Cause of Action. Report the civil statute directly related to the cause of action and give a brief description of the cause. Do not cite jurisdictional stanless diversity. Example: U.S. Civil Statute: 47 USC 553

Brief Description: Unauthorized reception of cable service

VII. Requested in Complaint. Class Action. Place an X in this box if you are filing a class action under Rule 23, F.R.Cv.P.

Demand. In this space enter the dollar amount (in thousands of dollars) being demanded or indicate other demand such as a preliminary injunction.

ury Demand. Check the appropriate box to indicate whether or not a jury is being demanded.

VIII. Related Cases. This section of the JS 44 is used to reference related pending cases if any. If there are related pending cases, insert the docket nund the corresponding judge names for such cases.

ate and Attorney Signature. Date and sign the civil cover sheet.


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ATTENTION!

N O T I C E F O R A L L P A R T I E S F I L I N G D O C U M E N T S

I N U . S . D I S T R I C T C O U R T

C O N C E R N I N G P R I V A C Y I S S U E S

P u r s u a n t t o F e d e r a l R u l e s o f C i v i l P r o c e d u r e 5 . 2 , a d d r e s s i n g

t h e p r i v a c y c o n c e r n s c r e a t e d b y i n t e r n e t a c c e s s t o c o u r t

d o c u m e n t s , u n l e s s o t h e r w i s e o r d e r e d b y t h e c o u r t , t h e f i l i n g

p a r t y s h a l l n o t i n c l u d e p e r s o n a l i n f o r m a t i o n i n p l e a d i n g s

a n d o t h e r

p a p e r s a s f o l l o w s :

( a ) S o c i a l S e c u r i t y N u m b e r s . I f a n i n d i v i d u a l s s o c i a l

s e c u r i t y n u m b e r m u s t b e i n c l u d e d i n a d o c u m e n t , o n l y t h e

l a s t f o u r d i g i t s o f t h a t n u m b e r s h a l l b e u s e d .

( b ) N a m e s o f M i n o r C h i l d r e n . I f t h e i n v o l v e m e n t o f a m i n o r

c h i l d m u s t b e m e n t i o n e d , o n l y t h e i n i t i a l s o f t h a t c h i l d

s h a l l b e u s e d .

( c ) D a t e o f B i r t h . I f a n i n d i v i d u a l s d a t e o f b i r t h m u s t

b e i n c l u d e d i n a d o c u m e n t , o n l y t h e y e a r s h a l l b e u s e d .

( d ) F i n a n c i a l A c c o u n t N u m b e r s . I f f i n a n c i a l a c c o u n t n u m b e r s

a r e r e l e v a n t , o n l y t h e l a s t f o u r d i g i t s o f t h e s e n u m b e r s

s h a l l b e u s e d .

O t h e r s e n s i t i v e p e r s o n a l i n f o r m a t i o n o f t h e l i t i g a n t ( o r

a n y o t h e r p e r s o n ) t h a t s h o u l d b e c o n s i d e r e d f o r p o s s i b l e

r e m o v a l o r r e d a c t i o n i n c l u d e s :

a n y p e r s o n a l i d e n t i f y i n g n u m b e r , i n c l u d i n g a d r i v e r s

l i c e n s e n u m b e r

m e d i c a l r e c o r d s

e m p l o y m e n t h i s t o r y

i n d i v i d u a l f i n a n c i a l i n f o r m a t i o n

p r o p r i e t a r y o r t r a d e s e c r e t i n f o r m a t i o n

i n f o r m a t i o n r e g a r d i n g a n i n d i v i d u a l s c o o p e r a t i o n w i t h

t h e g o v e r n m e n t

i n f o r m a t i o n r e g a r d i n g t h e v i c t i m o f a n y c r i m i n a l a c t i v i t y

n a t i o n a l s e c u r i t y i n f o r m a t i o n

s e n s i t i v e s e c u r i t y i n f o r m a t i o n


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IFP INSTRUCTIONS

I F Y O U C A N N O T A F F O R D T O P A Y T H E F I L I N G F E E y o u m a y b e a l l o w e d t oh a v e t h e f i l i n g f e e w a i v e d i f y o u f i l l o u t t h e f o l l o w i n g f o r m a n d

s e n d i t t o t h e c o u r t w i t h t h e c o m p l a i n t , c o v e r s h e e t a n d

c o m p l e t e d s u m m o n s f o r m s :

A p p l i c a t i o n t o P r o c e e d W i t h o u t P r e p a y m e n t o f F e e s a n d A f f i d a v i t

- ( A O 2 3 9 ( R e v . 1 / 0 9 ) )

W h e n y o u f i l e t h e c o m p l a i n t , c o v e r s h e e t , s u m m o n ( s ) a n d

A p p l i c a t i o n t o P r o c e e d W i t h o u t P r e p a y m e n t o f F e e s , e a c h o f t h e s e

w i l l b e r e v i e w e d a n d f o r w a r d e d t o a U n i t e d S t a t e s D i s t r i c t C o u r t

J u d g e f o r h i s o r h e r c o n s i d e r a t i o n . I f y o u r a p p l i c a t i o n i s

a p p r o v e d , t h e f i l i n g f e e w i l l b e w a i v e d a n d y o u r c a s e w i l l b e

d r a w n t o a U n i t e d S t a t e s D i s t r i c t J u d g e . I f y o u r A p p l i c a t i o n i sn o t a p p r o v e d , y o u m u s t p a y t h e f i l i n g f e e t o h a v e y o u r c a s e

f i l e d a n d d r a w n t o a U n i t e d S t a t e s D i s t r i c t J u d g e .

R E M E M B E R , i t i s v e r y i m p o r t a n t t o f i l l o u t t h e A p p l i c a t i o n t o

P r o c e e d W i t h o u t P r e p a y m e n t o f F e e s a n d A f f i d a v i t a s c o m p l e t e l y

a s p o s s i b l e !


7/26

Page 1 of 5

AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)

UNITED STATES DISTRICT COURTfor the

__________ District of __________

)))))

Plaintiff/Petitioner

v. Civil Action No.

Defendant/Respondent

APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS(Long Form)

Affidavit in Support of the Application

I am a plaintiff or petitioner in this case and declarethat I am unable to pay the costs of these proceedingsand that I am entitled to the relief requested. I declareunder penalty of perjury that the information below istrue and understand that a false statement may result ina dismissal of my claims.

Instructions

Complete all questions in this application and then sign it.Do not leave any blanks: if the answer to a question is 0,none, or not applicable (N/A), write that response. Ifyou need more space to answer a question or to explain youranswer, attach a separate sheet of paper identified with yourname, your case's docket number, and the question number.

Signed: Date:

1. For both you and your spouse estimate the average amount of money received from each of the following

sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly,semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductionsfor taxes or otherwise.

Income source Average monthly incomeamount during the past 12

months

Income amount expectednext month

You Spouse You SpouseEmployment

$ $ $ $

Self-employment$ $ $ $

Income from real property(such as rental income)

$ $ $ $

Interest and dividends$ $ $ $

Gifts$ $ $ $

Alimony$ $ $ $

Child support$ $ $ $


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Page 2 of 5


Retirement (such as social security, pensions, annuities,insurance)

$ $ $ $

Disability (such as social security, insurance payments)$ $ $ $

Unemployment payments $ $ $ $

Public-assistance (such as welfare)$ $ $ $

Other (specify):$ $ $ $

Total monthly income:$ $ $ $

2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes orother deductions.)

Employer Address Dates of employment Gross

monthly pay

$

$

3. List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is beforetaxes or other deductions.)

Employer Address Dates of employment Grossmonthly pay

$

$

$

4. How much cash do you and your spouse have? $

Below, state any money you or your spouse have in bank accounts or in any other financial institution.

Financial institution Type of account Amount you have Amount yourspouse has

$ $

$ $

$ $

If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts,expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts,perhaps because you have been in multiple institutions, attach one certified statement of each account.

0.00 0.00 0.00 0.00


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Page 3 of 5


5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinaryhousehold furnishings.

Assets owned by you or your spouse

Home (Value) $

Other real estate (Value)$

Motor vehicle #1 (Value) $

Make and year:

Model:

Registration #:

Motor vehicle #2 (Value) $

Make and year:

Model:

Registration #:

Other assets (Value) $

Other assets (Value) $

6. State every person, business, or organization owing you or your spouse money, and the amount owed.

Person owing you or your spousemoney

Amount owed to you Amount owed to your spouse

$ $

$ $

$ $

7. State the persons who rely on you or your spouse for support.

Name (or, if under 18, initials only) Relationship Age


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Page 4 of 5


8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by yourspouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show themonthly rate.

You Your spouse

Rent or home-mortgage payment (including lot rented for mobile home)$ $Are real estate taxes included? Yes No

Is property insurance included? Yes No

Utilities (electricity, heating fuel, water, sewer, and telephone) $ $

Home maintenance (repairs and upkeep) $ $

Food $ $

Clothing $ $

Laundry and dry-cleaning $ $

Medical and dental expenses $ $

Transportation (not including motor vehicle payments) $ $

Recreation, entertainment, newspapers, magazines, etc. $ $

Insurance (not deducted from wages or included in mortgage payments)

Homeowner's or renter's: $ $

Life: $ $

Health: $ $

Motor vehicle: $ $

Other: $ $

Taxes (not deducted from wages or included in mortgage payments) (specify):$ $

Installment payments

Motor vehicle: $ $

Credit card (name): $ $

Department store (name): $ $

Other: $ $

Alimony, maintenance, and support paid to others $ $


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Page 5 of 5


Regular expenses for operation of business, profession, or farm (attach detailedstatement)

$ $

Other (specify): $ $

Total monthly expenses: $ $

9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during thenext 12 months?

Yes No If yes, describe on an attached sheet.

10. Have you paid or will you be paying an attorney any money for services in connection with this case,including the completion of this form? Yes No

If yes, how much? $If yes, state the attorney's name, address, and telephone number:

11. Have you paid or will you be paying anyone other than an attorney (such as a paralegal or a typist) any moneyfor services in connection with this case, including the completion of this form? Yes No

If yes, how much? $If yes, state the person's name, address, and telephone number:

12. Provide any other information that will help explain why you cannot pay the costs of these proceedings.

13. Identify the city and state of your legal residence.

Your daytime phone number:

Your age: Your years of schooling:

Last four digits of your social-security number:

0.00 0.00

Print Save As... Add Attachment Reset


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1

I N T H E U N I T E D S T A T E S D I S T R I C T C O U R T

F O R T H E E A S T E R N D I S T R I C T O F N O R T H C A R O L I N A

_ _ _ _ _ _ _ _ _ _ _ _ _ D I V I S I O N

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ )

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ )

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ )

( E n t e r a b o v e t h e f u l l n a m e

o f t h e P l a i n t i f f [ s ] i n t h i s

a c t i o n ) .

C a s e N o . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

v s . ( T o b e a s s i g n e d

b y t h e C l e r k o f

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) D i s t r i c t C o u r t )

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ )

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ )

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ )

( E n t e r a b o v e t h e f u l l n a m e o f

A L L D e f e n d a n t [ s ] i n t h i s a c t i o n .

F e d . R . C i v . P . 1 0 ( a ) r e q u i r e s t h a t

t h e c a p t i o n o f t h e c o m p l a i n t

i n c l u d e t h e n a m e s o f a l l t h e

p a r t i e s . M e r e l y l i s t i n g o n e

p a r t y a n d e t a l . i s i n s u f f i c i e n t .

P l e a s e a t t a c h a d d i t i o n a l s h e e t s i f

n e c e s s a r y ) .

C O M P L A I N T

1 . P l a i n t i f f r e s i d e s a t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2 . D e f e n d a n t ( s ) n a m e ( s ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


13/26

2

L o c a t i o n o f p r i n c i p a l o f f i c e ( s ) o f t h e n a m e d d e f e n d a n t ( s ) :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

N a t u r e o f d e f e n d a n t ( s ) b u s i n e s s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

A p p r o x i m a t e n u m b e r o f i n d i v i d u a l s e m p l o y e d b y d e f e n d a n t :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3 . T h i s a c t i o n i s b r o u g h t p u r s u a n t t o T i t l e V I I o f t h e C i v i l

R i g h t s A c t o f 1 9 6 4 f o r e m p l o y m e n t d i s c r i m i n a t i o n . J u r i s d i c t i o n

i s s p e c i f i c a l l y c o n f e r r e d o n t h i s c o u r t b y 4 2 U . S . C . 2 0 0 0 e - 5 .

E q u i t a b l e a n d o t h e r r e l i e f a r e a l s o s o u g h t u n d e r 4 2 U . S . C .

2 0 0 0 3 - 5 ( g ) .

4 . T h e a c t s c o m p l a i n e d o f i n t h i s s u i t c o n c e r n :

( A ) _ _ _ _ _ _ F a i l u r e t o e m p l o y m e .

( B ) _ _ _ _ _ _ T e r m i n a t i o n o f m y e m p l o y m e n t .

( C ) _ _ _ _ _ _ F a i l u r e t o p r o m o t e m e .

( D ) _ _ _ _ _ _ O t h e r a c t s a s s p e c i f i e d b e l o w :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


14/26

3

5 . P l a i n t i f f i s :

( A ) _ _ _ _ _ _ p r e s e n t l y e m p l o y e d b y t h e d e f e n d a n t .

( B ) _ _ _ _ _ _ n o t p r e s e n t l y e m p l o y e d b y t h e d e f e n d a n t .

T h e d a t e s o f e m p l o y m e n t w e r e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .

E m p l o y m e n t w a s t e r m i n a t e d b e c a u s e :

( 1 ) _ _ _ _ _ _ p l a i n t i f f w a s d i s c h a r g e d .

( 2 ) _ _ _ _ _ _ p l a i n t i f f w a s l a i d o f f .

( 3 ) _ _ _ _ _ _ p l a i n t i f f l e f t j o b v o l u n t a r i l y .

6 . D e f e n d a n t ( s ) c o n d u c t i s d i s c r i m i n a t o r y w i t h r e s p e c t t o t h e

f o l l o w i n g :

( A ) _ _ _ _ _ _ m y r a c e .

( B ) _ _ _ _ _ _ m y r e l i g i o n .

( C ) _ _ _ _ _ _ m y s e x .

( D ) _ _ _ _ _ _ m y n a t i o n a l o r i g i n .

( E ) _ _ _ _ _ _ o t h e r a s s p e c i f i e d b e l o w :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7 . T h e n a m e ( s ) , r a c e , s e x , a n d t h e p o s i t i o n o r t i t l e o f t h e

i n d i v i d u a l ( s ) w h o a l l e g e d l y d i s c r i m i n a t e d a g a i n s t m e d u r i n g t h e

p e r i o d o f m y e m p l o y m e n t w i t h t h e d e f e n d a n t c o m p a n y i s ( a r e ) :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


15/26

4

8 . T h e a l l e g e d d i s c r i m i n a t i o n o c c u r r e d o n o r a b o u t _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .

9 . T h e n a t u r e o f m y c o m p l a i n t , i . e . , t h e m a n n e r i n w h i c h t h e

i n d i v i d u a l s ( s ) n a m e d a b o v e d i s c r i m i n a t e d a g a i n s t m e i n t e r m s o f

t h e c o n d i t i o n s o f m y e m p l o y m e n t i s a s f o l l o w s :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .

1 0 . T h e a l l e g e d i l l e g a l a c t i v i t y t o o k p l a c e a t : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1 1 . I f i l e d c h a r g e s w i t h t h e E q u a l E m p l o y m e n t O p p o r t u n i t y

C o m m i s s i o n r e g a r d i n g d e f e n d a n t ( s ) a l l e g e d d i s c r i m i n a t o r y c o n d u c t

o n o r a b o u t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . I h a v e a t t a c h e d a c o p y o f

t h e N o t i c e o f R i g h t t o S u e l e t t e r i s s u e d b y t h e E q u a l E m p l o y m e n t

O p p o r t u n i t y C o m m i s s i o n . T h i s l e t t e r w a s r e c e i v e d b y m e o n _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .


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5

1 2 . I s e e k t h e f o l l o w i n g r e l i e f :

( A ) _ _ _ _ _ _ r e c o v e r y o f b a c k p a y ;

( B ) _ _ _ _ _ _ r e i n s t a t e m e n t t o m y f o r m e r j o b ;

( C ) _ _ _ _ _ _ t r i a l b y j u r y o n a l l i s s u e s s o t r i a b l e ;

a n d a n y o t h e r r e l i e f a s m a y b e a p p r o p r i a t e , i n c l u d i n g

i n j u n c t i v e o r d e r s , d a m a g e s , c o s t s a n d a t t o r n e y s f e e s .

_ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _

D a t e S i g n a t u r e o f P l a i n t i f f

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

A d d r e s s a n d P h o n e N u m b e r o f P l a i n t i f f


17/26

IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF NORTH CAROLINA

Case No.

)

)Plaintiff(s), )

)

vs )

)

)

Defendant(s).DISCLOSURE OF CORPORATE AFFILIATIONS AND OTHER ENTITIES WITH A

DIRECT FINANCIAL INTEREST IN LITIGATION

Pursuant to Fed.R.Civ.P. 7.1 and Local Civil Rule 7.3, or Fed.R.Crim.P. 12.4 and Local CriminalRule 12.3,

_______________________ who is ______________________,

(name of party) (plaintiff/defendant/other:_______________)

makes the following disclosure:

1. Is party a publicly held corporation or other publicly held entity?

YES NO

2. Does party have any parent corporations?

YES NO

If yes, identify all parent corporation, including grandparent and great-grandparent corporations:

3. Is 10% or more of the stock of a party owned by a publicly held corporation or other

publicly held entity?

YES NO

If yes, identify all such owners:

)


18/26

4. Is there any other publicly held corporation or other publicly held entity that has a direct

financial interest in the outcome of the litigation (Local Civil Rule 7.3 or Local Criminal Rule 12.3)?

YES NO

If yes, identify entity and nature of interest:

5. Is party a trade association?

YES NO

If yes, identify all members of the association, their parent corporations, and any publicly held

companies that own 10% or more of a members stock:

6. If case arises out of a bankruptcy proceeding, identify any trustee and the members of any

creditorss committee:

Signature: _____________________________

Date: _____________________________

Finalize Form Reset For


19/26

A T T A C H M E N T A


20/26

I N S T R U C T I O N S F O R M A K I N G S E R V I C E O N T H E U N I T E D S T A T E S ,

I T S A G E N C I E S , C O R P O R A T I O N S , A N D O F F I C E R S

T h e r u l e s f o r s e r v i c e o n t h e U n i t e d S t a t e s , i t s a g e n c i e s ,

c o r p o r a t i o n s , o f f i c e r s o r e m p l o y e e s a r e s t a t e d i n R u l e 4 ( I )o f t h e F e d e r a l R u l e s o f C i v i l P r o c e d u r e .

W H E N T H E U N I T E D S T A T E S O F A M E R I C A I S L I S T E D A S A D E F E N D A N T

E x a m p l e : J o h n D o e v . U n i t e d S t a t e s o f A m e r i c a

T h e c o m p l a i n t a n d s u m m o n s m u s t b e s e r v e d a s f o l l o w s o n t h e :

( 1 ) U n i t e d S t a t e s A t t o r n e y : B y e i t h e r ( a ) s e n d i n g t h e

c o m p l a i n t a n d s u m m o n s b y r e g i s t e r e d o r c e r t i f i e d m a i l

t o t h e a t t e n t i o n o f t h e c i v i l p r o c e s s c l e r k i n t h e U . S .

A t t o r n e y s O f f i c e i n t h e d i s t r i c t w h e r e t h e c o m p l a i n t

i s f i l e d ; o r ( b ) p e r s o n a l l y d e l i v e r i n g t h e s u m m o n s a n d

c o m p l a i n t t o t h e U n i t e d S t a t e s A t t o r n e y f o r t h e

d i s t r i c t w h e r e t h e c o m p l a i n t i s f i l e d .

( 2 ) A t t o r n e y G e n e r a l : B y s e n d i n g a c o p y o f t h e s u m m o n s a n d

c o m p l a i n t b y r e g i s t e r e d o r c e r t i f i e d m a i l t o t h e U n i t e d

S t a t e s A t t o r n e y G e n e r a l i n W a s h i n g t o n , D C .

I f y o u r c o m p l a i n t a t t a c k s t h e v a l i d i t y o f a n o r d e r o f a n o f f i c e r

o r a g e n c y n o t l i s t e d a s a p a r t y t o y o u r c a s e , y o u m u s t a l s o s e r v e

t h e c o m p l a i n t a n d s u m m o n s b y r e g i s t e r e d o r c e r t i f i e d m a i l o n t h e

o f f i c e r o r a g e n c y t h a t i s s u e d t h e o r d e r .

W H E N A F E D E R A L O F F I C E R , A G E N C Y O R C O R P O R A T I O N I S L I S T E D A S A

D E F E N D A N T

E x a m p l e s : J o h n D o e v . M i c h a e l A s t r u e , C o m m i s s i o n e r o f S o c i a l

S e c u r i t y

J a n e D o e v . I n t e r n a l R e v e n u e S e r v i c e

T h e c o m p l a i n t a n d s u m m o n s m u s t b e s e r v e d a s f o l l o w s o n t h e :

( 1 ) U n i t e d S t a t e s : B y s e r v i n g t h e U . S . A t t o r n e y a n d

A t t o r n e y G e n e r a l ( s e e a b o v e s t e p s 1 a n d 2 )

( 2 ) F e d e r a l O f f i c e r , A g e n c y o r C o r p o r a t i o n : B y s e n d i n g a

c o p y o f t h e c o m p l a i n t a n d s u m m o n s b y r e g i s t e r e d o r

c e r t i f i e d m a i l t o t h e f e d e r a l o f f i c e r , a g e n c y o r

c o r p o r a t i o n n a m e d a s a d e f e n d a n t .


21/26

AO 440 (Rev. 12/09) Summons in a Civil Action


__________ District of __________

)

))))))

Plaintiff

v. Civil Action No.

Defendant

SUMMONS IN A CIVIL ACTION

To: (Defendants name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) or 60 days if youare the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.P. 12 (a)(2) or (3) you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 ofthe Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiffs attorney,whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint.You also must file your answer or motion with the court.

CLERK OF COURT

Date:Signature of Clerk or Deputy Clerk


22/26


23/26


24/26

AO 440 (Rev. 12/09) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on(date) .

I personally served the summons on the individual at (place)

on (date) ; or

I left the summons at the individuals residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individuals last known address; or

I served the summons on (name of individual) , who is

designated by law to accept service of process on behalf of(name of organization)

on (date) ; or

I returned the summons unexecuted because ; or

Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:Servers signature

Printed name and title

Servers address

Additional information regarding attempted service, etc:

0.00

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25/26

AO 440 (Rev. 12/09) Summons in a Civil Action


__________ District of __________

)

))))))

Plaintiff

v. Civil Action No.

Defendant

SUMMONS IN A CIVIL ACTION

To: (Defendants name and address)

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) or 60 days if youare the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.P. 12 (a)(2) or (3) you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 ofthe Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiffs attorney,whose name and address are:

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint.You also must file your answer or motion with the court.

CLERK OF COURT

Date:Signature of Clerk or Deputy Clerk


26/26

AO 440 (Rev. 12/09) Summons in a Civil Action (Page 2)

Civil Action No.

PROOF OF SERVICE

(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any)

was received by me on(date) .

I personally served the summons on the individual at (place)

on (date) ; or

I left the summons at the individuals residence or usual place of abode with (name)

, a person of suitable age and discretion who resides there,

on (date) , and mailed a copy to the individuals last known address; or

I served the summons on (name of individual) , who is

designated by law to accept service of process on behalf of(name of organization)

on (date) ; or

I returned the summons unexecuted because ; or

Other (specify):

.

My fees are $ for travel and $ for services, for a total of $ .

I declare under penalty of perjury that this information is true.

Date:Servers signature

Printed name and title

Servers address

Additional information regarding attempted service, etc:

0.00

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