Free pro_se.pdf - North Carolina

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF NORTH CAROLINA

FORMS FOR FILING CASES PRO SE (Representing Yourself)

Revised 11/15/2006

ATTACHMENTS FORM A: FORM B: FORM C: FORM D: Guidelines for Filing Civil Cases Pro Se [Non-Prisoner] Complaint Form Civil Cover Sheet (Form JS-44) filed in Triplicate Application to Proceed without Prepayment of Fees and Affidavit (IFP Application) Summons in a Civil Case Notice of Lawsuit and Request for Waiver of Service of Summons Waiver of Service of Summons Notice of Right to Consent to the Exercise of Civil Jurisdiction by a Magistrate Judge

FORM E: FORM F: FORM G: FORM H:

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF NORTH CAROLINA

GUIDE FOR FILING CIVIL CASES CIVIL COVER SHEET (Form JS 44) SUMMONS COMPLAINT Required in triplicate. See detailed instructions on back of form. (If a removal case, cover sheet filed with Notice of Removal.) Original plus two for each party to be served. Original and a copy for each defendant to be served. Paper should be unfolded, letter size with page numbered at the bottom. If typewritten, it should be double spaced. SEE ATTACHMENT FOR INSTRUCTIONS ON HOW TO DRAFT A COMPLAINT IN FEDERAL COURT. SIGNATURE The complaint, unless Pro Se, must be signed by at least member of the bar of this Court [L.R. 83.1(c)(2)]. Counsel's name, complete address, telephone number, N.C. Bar Number, and party represented must be shown on all pleadings. (If Pro Se, name, address, and telephone number must be shown.) $350.00 check or money order payable to the Clerk, U.S. District Court for each complaint or petition for removal. U.S. District Court 324 W. Market Street Greensboro, NC 27401

COURT FEES

COURT ADDRESS

HOW TO DRAFT A COMPLAINT IN FEDERAL COURT

All suits in federal court must begin with the filing of a complaint. The basic guide for drafting a complaint in federal court is the Federal Rules of Civil Procedure, particularly Rule 8 and 10, and the Local Rules for the Middle District of North Carolina, particularly Rules 7.1 and 3.1. The attachment shows the proper format. In general, your complaint should have the following elements: a caption; a statement of you address; a statement of the defendant(s) identity and address; and, a statement invoking federal jurisdiction (that is, why you are suing in federal court and not state court). You should try to list the specific statute(s) under which you are claiming jurisdiction, such as: Federal Question, 28 U.S.C. § 1331; Diversity of Citizenship, 28 U.S.C. § 1332; or a Violation of Civil Rights, 42 U.S.C. § 1983 or 28 U.S.C. § 1343. After your statement of federal jurisdiction, you should set forth, clearly and concisely the facts of your claim. Names, dates, and events should be described accurately and briefly. Paragraphs should be numbered. Lastly, you should state your claim for relief (that is, what you want the court to do for you). Relief may include money damages, injunctive relief or both. In addition, you should state whether you wish a trial by jury. You must then sign your complaint and provide your address and telephone number. Complaints may be typed or handwritten, but must be double spaced. (Note: this instruction sheet is not double spaced.) You must submit one original for the court and one copy for each defendant sued. If you sue the defendant in his individual and official capacity, two copies are required (one for his individual capacity, and one for his official capacity). If you sue the United States, or an agency thereof, you must submit three (3) copies for each entity sued. Remember to keep a copy for yourself. The fee for filing a complaint is $350.00. If you cannot afford to pay this fee, you may petition the court to waive prepayment of the filing fee. This is done by filing a motion to proceed "in forma pauperis." This form is available from the court. Lastly, you are responsible for serving the complaint on the defendant(s) (unless the court orders the United States Marshal to serve your complaint). See Federal Rule of Civil Procedure 4 for proper service requirements. Be sure to follow these instructions carefully. Papers which do not comply with these instructions may be subject to a deficiency order by the Court.

Rev. 6/03

UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF NORTH CAROLINA Pro se [Non-prisoner] Complaint Form

________________________________,
(Your Name)

Plaintiff,

v.

Defendant(s).

) ) ) ) ) ) ) ) ) ) ) )

Civil Action No. (to be assigned by the Clerk)

COMPLAINT I. JURISDICTION ______________________________________________________________________ II. A. PARTIES Plaintiff Name of Plaintiff: Address:

B.

Defendant(s) (Notice: A person must be identified in subsections B and C in order to be considered as a defendant.) Name of Defendant: Current Address:

C.

Additional Defendants (please provide the same information for each defendant as listed in Item B above):

III.

STATEMENT OF CLAIM (State here as briefly as possible the FACTS of your case. Do this by identifying the alleged legal wrong and by describing how each defendant named in Section II.B. and C. above is personally responsible for depriving you of your rights. Include relevant times, dates, and places. Also, you must state the basis for federal jurisdiction. In other words, why should the case be in federal court as opposed to state court. DO NOT GIVE LEGAL ARGUMENTS OR CITE ANY CASES. Number and set forth each separate claim in a separate paragraph.) (Attach extra sheets if necessary.)

III.

STATEMENT OF CLAIM - continued.

IV.

RELIEF State briefly and exactly what relief you want from this court.

Signed this

day of

, 20

.

Signature of plaintiff

Address

Telephone number

OJS 44 (Rev. 11/04)

CIVIL COVER SHEET

The 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 provided by 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 initiating the civil docket sheet. (SEE INSTRUCTIONS ON THE REVERSE OF THE FORM.)

I. (a)

PLAINTIFFS

DEFENDANTS

(b) County of Residence of First Listed Plaintiff
(EXCEPT IN U.S. PLAINTIFF CASES)

County of Residence of First Listed Defendant
(IN U.S. PLAINTIFF CASES ONLY) NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF THE LAND INVOLVED.

(c) Attorney's (Firm Name, Address, and Telephone Number)

Attorneys (If Known)

II. BASIS OF JURISDICTION
'1
U.S. Government Plaintiff

(Place an "X" in One Box Only)

III. CITIZENSHIP OF PRINCIPAL PARTIES(Place an "X" in One Box for Plaintiff
(For Diversity Cases Only) and One Box for Defendant) DEF PTF Incorporated or Principal Place of Business In This State Incorporated and Principal Place of Business In Another State Foreign Nation DEF PTF Citizen of This State

' 3 Federal Question
(U.S. Government Not a Party)

' 1 ' 2 ' 3

' 1 ' 2 ' 3

' 4 ' 5 ' 6

'4 ' 5 ' 6

'2

U.S. Government Defendant

' 4 Diversity
(Indicate Citizenship of Parties in Item III)

Citizen of Another State

Citizen or Subject of a Foreign Country

IV. NATURE OF SUIT
CONTRACT

(Place an "X" in One Box Only) TORTS

FORFEITURE/PENALTY

BANKRUPTCY

OTHER STATUTES

' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' '

110 Insurance 120 Marine 130 Miller Act 140 Negotiable Instrument 150 Recovery of Overpayment & Enforcement of Judgment 151 Medicare Act 152 Recovery of Defaulted Student Loans (Excl. Veterans) 153 Recovery of Overpayment of Veteran's Benefits 160 Stockholders' Suits 190 Other Contract 195 Contract Product Liability 196 Franchise REAL PROPERTY 210 Land Condemnation 220 Foreclosure 230 Rent Lease & Ejectment 240 Torts to Land 245 Tort Product Liability 290 All Other Real Property

' ' ' ' ' ' ' ' ' ' ' ' ' ' ' '

PERSONAL INJURY 310 Airplane 315 Airplane Product Liability 320 Assault, Libel & Slander 330 Federal Employers' Liability 340 Marine 345 Marine Product Liability 350 Motor Vehicle 355 Motor Vehicle Product Liability 360 Other Personal Injury CIVIL RIGHTS 441 Voting 442 Employment 443 Housing/ Accommodations 444 Welfare 445 Amer. w/Disabilities Employment 446 Amer. w/Disabilities Other 440 Other Civil Rights

PERSONAL INJURY ' 362 Personal Injury Med. Malpractice ' 365 Personal Injury Product Liability ' 368 Asbestos Personal Injury Product Liability PERSONAL PROPERTY ' 370 Other Fraud ' 371 Truth in Lending ' 380 Other Personal Property Damage ' 385 Property Damage Product Liability PRISONER PETITIONS

' 610 Agriculture ' 620 Other Food & Drug ' 625 Drug Related Seizure ' ' ' ' ' ' ' ' ' ' '
of Property 21 USC 881 630 Liquor Laws 640 R.R. & Truck 650 Airline Regs. 660 Occupational Safety/Health 690 Other LABOR 710 Fair Labor Standards Act 720 Labor/Mgmt. Relations 730 Labor/Mgmt.Reporting & Disclosure Act 740 Railway Labor Act 790 Other Labor Litigation 791 Empl. Ret. Inc. Security Act

' 422 Appeal 28 USC 158 ' 423 Withdrawal
28 USC 157 PROPERTY RIGHTS

' 820 Copyrights ' 830 Patent ' 840 Trademark
SOCIAL SECURITY 861 HIA (1395ff) 862 Black Lung (923) 863 DIWC/DIWW (405(g)) 864 SSID Title XVI 865 RSI (405(g)) FEDERAL TAX SUITS ' 870 Taxes (U.S. Plaintiff or Defendant) ' 871 IRS--Third Party 26 USC 7609

' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' '

' ' ' ' '

' 510 Motions to Vacate ' ' ' ' '
Sentence Habeas Corpus: 530 General 535 Death Penalty 540 Mandamus & Other 550 Civil Rights 555 Prison Condition

400 State Reapportionment 410 Antitrust 430 Banks and Banking 450 Commerce 460 Deportation 470 Racketeer Influenced and Corrupt Organizations 480 Consumer Credit 490 Cable/Sat TV 810 Selective Service 850 Securities/Commodities/ Exchange 875 Customer Challenge 12 USC 3410 890 Other Statutory Actions 891 Agricultural Acts 892 Economic Stabilization Act 893 Environmental Matters 894 Energy Allocation Act 895 Freedom of Information Act 900Appeal of Fee Determination Under Equal Access to Justice 950 Constitutionality of State Statutes

V. ORIGIN
'1
Original Proceeding

(Place an "X" in One Box Only)

' 2

' 3 Remanded from ' 4 Reinstated or ' 5 Transferred from ' 6 Multidistrict Removed from another district State Court Appellate Court Reopened Litigation (specify) Cite the U.S. Civil Statute under which you are filing (Do not cite jurisdictional statutes unless diversity):
Brief description of cause: DEMAND $

' 7

Appeal to District Judge from Magistrate Judgment

VI. CAUSE OF ACTION

' CHECK IF THIS IS A CLASS ACTION VII. REQUESTED IN UNDER F.R.C.P. 23 COMPLAINT: VIII. RELATED CASE(S) (See instructions): JUDGE IF ANY
DATE

CHECK YES only if demanded in complaint: ' Yes ' No JURY DEMAND: DOCKET NUMBER

SIGNATURE OF ATTORNEY OF RECORD

FOR OFFICE USE ONLY RECEIPT # AMOUNT APPLYING IFP JUDGE MAG. JUDGE

JS 44 Reverse (Rev. 11/04)

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 required by 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 the use of 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 complaint filed. The attorney filing a case should complete the form as follows: I. (a) Plaintiffs-Defendants. Enter names (last, first, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency, use only the 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, giving both 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 the time of 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 cases, the 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, noting in this section "(see attachment)". II. 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" in one of 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. Federal question. (3) This refers to suits under 28 U.S.C. 1331, where jurisdiction arises under the Constitution of the United States, an amendment to the Constitution, 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, and box 1 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 of the different parties must be checked. (See Section III below; federal question actions take precedence over diversity cases.) III. Residence (citizenship) of Principal Parties. This section of the JS 44 is to be completed if diversity of citizenship was indicated above. Mark this section for each principal party. IV. 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 sufficient to 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, select the 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. Removed 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 petition for removal is granted, check this box. Remanded 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. Reinstated or Reopened. (4) Check this box for cases reinstated or reopened in the district court. Use the reopening date as the filing date. Transferred 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 multidistrict litigation 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 this box is checked, do not check (5) above. Appeal to District Judge from Magistrate Judgment. (7) Check this box for an appeal from a magistrate judge's 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 statutes unless 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. Jury 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 numbers and the corresponding judge names for such cases. Date and Attorney Signature. Date and sign the civil cover sheet.

Rev. 12/05 IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF NORTH CAROLINA , (Your Name) Plaintiff, v. ) ) ) ) ) APPLICATION FOR LEAVE TO PROCEED ) IN FORMA PAUPERIS ) AND AFFIDAVIT/DECLARATION IN SUPPORT

) ) ) ) ) , ) ) Defendant(s) )

I, , request leave of Court to proceed in the above-entitled action without prepayment of fees and costs or giving security therefor. In support of this request, I state that I am unable to pay such costs or give security therefor and that I believe that I am entitled to redress. The nature of this action is:

I understand that any false statements or answer to any question in this application may subject me to the penalties for perjury. 1. Are you presently employed? Yes No a. If the answer is yes, state the amount of your salary or wages per month, and give the name address of your employer.

b. If the answer is no, state the date of last employment and the amount of the salary and wages per month which you received.

No No Spouse 2. Is your spouse presently employed? Yes a. If the answer is yes, state the amount of your salary or wages per month, and give the name address of your employer. b. If the answer is no, state the date of last employment and the amount of the salary and wages per month which you received.

3. Have you received within the past twelve months any money from any of the following sources: a. Business, profession, or form of self-employment? b. Rent payments, interest, or dividends? c. Pensions, annuities, or insurance? d. Social Security, SSI or disability? e. Workers' Compensation or Unemployment? f. Child Support? g. AFDC, WIC or Food Stamps? h. Gifts or inheritances? i. Any other sources? Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No

If the answer to any of the above is yes, describe each source of money and state the amount received from each during the past twelve months.

4. Has your spouse received within the past twelve months any money from any of the sources listed in question No. 3? Yes No No Spouse

If the answer to any of the above is yes, describe each source of money and state the amount received from each during the past twelve months.

5. Do you and your spouse, if any, own any cash, or have money in a checking, savings, or any other financial account? Yes No

If the answer is yes, state the total value of the items owned.

-2-

6. Do you and your spouse, if any, own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No

If the answer is yes, describe the property and state its approximate value.

7. List the persons who are dependant upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support.

8. List your debts, obligations, and creditors, including banks, loan companies, charge accounts, and monthly bills. Creditior Total Debt Monthly Payment

I declare under penalty of perjury that the following is true and correct.

Executed on (Date)

. (Signature of Plaintiff)

OAO 440 (Rev. 8/01) Summons in a Civil Action

-3-

UNITED STATES DISTRICT COURT
MIDDLE District of NORTH CAROLINA

SUMMONS IN A CIVIL CASE
V.

CASE NUMBER:

TO: (Name and address of Defendant)

YOU ARE HEREBY SUMMONED and required to serve on PLAINTIFF'S ATTORNEY (name and address)

an answer to the complaint which is served on you with this summons, within days after service of this summons on you, exclusive of the day of service. If you fail to do so, judgment by default will be taken against you for the relief demanded in the complaint. Any answer that you serve on the parties to this action must be filed with the Clerk of this Court within a reasonable period of time after service.

CLERK

DATE

(By) DEPUTY CLERK

OAO 398

(Rev. 12/93)

NOTICE OF LAWSUIT AND REQUEST FOR WAIVER OF SERVICE OF SUMMONS

TO: (A) as (B) of (C)

A lawsuit has been commenced against you (or the entity on whose behalf you are addressed). A copy of the complaint is attached to this notice. It has been filed in the United States District Court for the (D) MIDDLE District of NORTH CAROLINA and has been assigned docket number (E) . This is not a formal summons or notification from the court, but rather my request that you sign and return the enclosed waiver of service in order to save the cost of serving you with a judicial summons and an additional copy of the complaint. The cost of service will be avoided if I receive a signed copy of the waiver within (F) days after the date designated below as the date on which this Notice and Request is sent. I enclose a stamped and addressed envelope (or other means of cost-free return) for your use. An extra copy of the waiver is also attached for your records.

If you comply with this request and return the signed waiver, it will be filed with the court and no summons will be served on you. The action will then proceed as if you had been served on the date the waiver is filed, except that you will not be obligated to answer the complaint before 60 days from the date designated below as the date on which this notice is sent (or before 90 days from that date if your address is not in any judicial district of the United States). If you do not return the signed waiver within the time indicated, I will take appropriate steps to effect formal service in a manner authorized by the Federal Rules of Civil Procedure and will then, to the extent authorized by those Rules, ask the court to require you (or the party on whose behalf you are addressed) to pay the full costs of such service. In that connection, please read the statement concerning the duty of parties to waive the service of the summons, which is set forth at the foot of the waiver form. I affirm that this request is being sent to you on behalf of the plaintiff, this , . day of

Signature of Plaintiff's Attorney or Unrepresented Plaintiff

A--Name of individual defendant (or name of officer or agent of corporate defendant) B--Title, or other relationship of individual to corporate defendant C--Name of corporate defendant, if any D--District E--Docket number of action F--Addressee must be given at least 30 days (60 days if located in foreign country) in which to return waiver

OAO 399

(Rev. 10/95)

WAIVER OF SERVICE OF SUMMONS
TO:
(NAME OF PLAINTIFF'S ATTORNEY OR UNREPRESENTED PLAINTIFF)

I,
(DEFENDANT NAME)

, acknowledge receipt of your request

that I waive service of summons in the action of
(CAPTION OF ACTION)

, in the United States District Court

which is case number
(DOCKET NUMBER)

for the

MIDDLE

District of

NORTH CAROLINA

.

I have also received a copy of the complaint in the action, two copies of this instrument, and a means by which I can return the signed waiver to you without cost to me. I agree to save the cost of service of a summons and an additional copy of the complaint in this lawsuit by not requiring that I (or the entity on whose behalf I am acting) be served with judicial process in the manner provided by Rule 4. I (or the entity on whose behalf I am acting) will retain all defenses or objections to the lawsuit or to the jurisdiction or venue of the court except for objections based on a defect in the summons or in the service of the summons. I understand that a judgment may be entered against me (or the party on whose behalf I am acting) if an answer or motion under Rule 12 is not served upon you within 60 days after
(DATE REQUEST WAS SENT)

,

or within 90 days after that date if the request was sent outside the United States.

(DATE)

(SIGNATURE)

Printed/Typed Name: As
(TITLE)

of
(CORPORATE DEFENDANT)

Duty to Avoid Unnecessary Costs of Service of Summons
Rule 4 of the Federal Rules of Civil Procedure requires certain parties to cooperate in saving unnecessary costs of service of the summons and complaint. A defendant located in the United States who, after being notified of an action and asked by a plaintiff located in the United States to waive service of summons, fails to do so will be required to bear the cost of such service unless good cause be shown for its failure to sign and return the waiver. It is not good cause for a failure to waive service that a party believes that the complaint is unfounded, or that the action has been brought in an improper place or in a court that lacks jurisdiction over the subject matter of the action or over its person or property. A party who waives service of the summons retains all defenses and objections (except any relating to the summons or to the service of the summons), and may later object to the jurisdiction of the court or to the place where the action has been brought. A defendant who waives service must within the time specified on the waiver form serve on the plaintiff's attorney (or unrepresented plaintiff) a response to the complaint and must also file a signed copy of the response with the court. If the answer or motion is not served within this time, a default judgment may be taken against that defendant. By waiving service, a defendant is allowed more time to answer than if the summons had been actually served when the request for waiver of service was received.

IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF NORTH CAROLINA

Re: Case NOTICE OF RIGHT TO CONSENT TO THE EXERCISE OF CIVIL JURISDICTION BY A MAGISTRATE JUDGE

Your attention is invited to Title 28 U.S.C. § 636(c). You are hereby notified that is all parties to a civil case consent, the United States magistrate judges of this district court, in addition to their other duties, may conduct a trial pursuant to 28 U.S.C. § 636(c)(1) and order the entry of a final judgment. Your decision to consent, or not to consent, to the referral of your case to a United States magistrate judge for trial and entry of a final judgment must be entirely voluntary. The judge or magistrate judge to whom the case has been assigned will not be informed of your decision unless all parties agree that the case may be referred to a magistrate judge for these specific purposes. A less than unanimous decision will not be communicated by my office to either the judge or magistrate judge. Copies of the form for the "Consent to Proceed Before a United States Magistrate Judge" are available from my office.

Date

JOHN S. BRUBAKER, Clerk of Court

Additional Legal Services Programs

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