Free Complaint - Nebraska


File Size: 10.8 kB
Pages: 6
File Format: PDF
State: Nebraska
Category: Court Forms - Federal
Author: JLS
Word Count: 507 Words, 3,101 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ned.uscourts.gov/forms/ProSeComplaintForm.pdf

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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEBRASKA

PRO SE CIVIL COMPLAINT
Case No. ___________________ (the court will assign a number)

I.

CASE CAPTION:

Parties to this Civil Action:

Pursuant to Fed. R. Civ. P. 10(a), the names of all parties must appear in the case caption. The court will not consider a claim against any defendant who is not listed in the caption.

A.

Plaintiff(s) Name(s):

Address(es):

Telephone No. (only if you are NOT a prisoner)

B.

Defendant(s) Name(s):

Address(es) If known:

(Attach extra sheets if necessary.)
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II. STATEMENT OF CLAIM(S) State briefly the facts of your claim. Describe how each defendant is involved. You do not need to give legal arguments or cite cases or statutes. Use as much space as you need to state the facts. (Attach extra sheets if necessary.)

A.

When did the events occur?

B.

What happened?

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II. STATEMENT OF CLAIM(S) (continued)

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III. STATEMENT OF JURISDICTION Check any of the following that apply to this case (you may check more than one): ______United States or a federal official or agency is a party ______Claim arises under the Constitution, laws or treaties of the United States ______Violation of civil rights ______Employment discrimination ______Diversity of Citizenship (a matter between citizens of different states in which the amount in controversy exceeds $75,000) ______Other basis for jurisdiction in federal court (explain below)

IV.

STATEMENT OF VENUE

State briefly the connection between this case and Nebraska. For example, does a party reside or do business in Nebraska? Is a party incorporated in Nebraska? Did an injury occur in Nebraska? Did the claim arise in Nebraska?

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V.

RELIEF

State briefly what you want the court to do for you.

VI.

EXHAUSTION OF ADMINISTRATIVE PROCEDURES

Some claims, but not all, require exhaustion of administrative procedures. Answer the questions below to the best of your ability. A. Have the claims which you make in this civil action been presented through any type of administrative procedure within any state or federal government agency? Yes _____________ No _____________

B.

If you answered yes, state the date your claims were so presented, how they were presented, and the result of that procedure:

C.

If you answered no, give the reasons, if applicable, why the claims made in this action have not been presented through administrative procedures:

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VII.

ARE YOU REQUESTING TRIAL BY A JURY OR BY A JUDGE? (check one):

JURY _____________

JUDGE _____________

VIII. VERIFICATION

I (we) declare under penalty of perjury that the foregoing is true and correct.

Date(s) Executed:

Signature(s) of Plaintiff(s):

Note: IF YOU CANNOT AFFORD TO PAY THE COURT'S FILING FEE UPON THE FILING OF YOUR COMPLAINT, THERE IS A SEPARATE FORM TO BE USED FOR APPLYING TO PROCEED IN FORMA PAUPERIS. Also, if there is more than one plaintiff in the case who wishes to proceed in forma pauperis, each such plaintiff must submit a separate application to proceed in forma pauperis.

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