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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 Zip Code (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). 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 an attached sheet of paper). the back side of this sheet). A. Name of plaintiff___________________________________________________ Address___________________________________________________________ __________________________________________________________________ __________________________________________________________________

Case Number: _______________

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(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. Defendant________________________________________________________is 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. 2. Plaintiff is a citizen of the State of __________. 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 2

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). 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_____. 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). 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].) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3

_____ 2.

_____ 3.

________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. IV. Relief: (State briefly exactly what judgement or relief you want from the Court. Do not make legal arguments.) ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. V. Do you claim the wrongs alleged in your complaint are continuing to occur at the present time? Yes [ ] No [ ] Do you claim actual damages for the acts alleged in your complaint? 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. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Yes [ ] No [ ]

VI. VII.

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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 [ ] 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: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

B.

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)

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___________________________________ Address ___________________________________ City State Zip Code ___________________________________ Telephone Number

DESIGNATION OF PLACE OF TRIAL

Plaintiff designates ( Wichita, trial in this matter.

Kansas City or (circle one location) (check one location)

Topeka ), Kansas as the location for the

_______________________________ Signature of Plaintiff

REQUEST FOR TRIAL BY JURY

Plaintiff requests trial by jury ( yes or no ). no . yes (circle one) (check one)

________________________________ Signature of Plaintiff Dated: __________ (Rev. 8/07)

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Additional Information

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________