Free Pro Se Packet - West Virginia


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State: West Virginia
Category: Court Forms - Federal
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UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF WEST VIRGINIA

GUIDE FOR FILING FEDERAL CIVIL SUITS
The following information explains court procedures and requirements. Each case filed with the Court is unique and must satisfy certain legal standards. You should not rely on this information to identify those standards. You should be especially mindful that there are certain time limits within which lawsuits must be brought, or in which to answer lawsuits brought by others. Failure to observe those time limits could be prejudicial and may result in the case being dismissed or otherwise decided against you. To initiate a civil action in this Court, you must complete the following documents and submit them to the Clerk of Court for filing: COMPLAINT A guide for preparing your complaint is enclosed. Make sure to follow these guidelines: -complete all forms as thoroughly as possible -use letter size paper only (81/2 x 11) -sign all documents -send the original and one copy for each named defendant -do not use staples -do not use pencil: use black or blue pens only -do not bind documents -write only on the fronts of documents, do not write on the backs of documents Set up your complaint in the manner shown below, using the heading of the court at the top as shown, naming the parties (plaintiff vs. defendant) and stating in the body of the complaint your claim and demand for relief. Sign and date the complaint at the end. Complaints against state personnel are filed under 42 U.S.C. § 1983; complaints against federal personnel are filed under 28 USC 1331b and Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics, 403 U.S. 388 (1971). Do NOT use 42 U.S.C. § 1983 to apply for a writ of habeas corpus or to challenge the sentence you received in state or federal court. SUMMONS The rules require that the Clerk of Court issue the Summons, but you should prepare the summons and submit the original and two copies to the court, plus an additional copy for each defendant, for issuance by the Clerk. If you are suing an agency for the government, submit an original and six (6) copies. Some forms are enclosed for your use.

FILING FEE, APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT The FILING FEE for filing a civil action in federal court is $350.00 (money order or credit card only; no cash or personal checks accepted; make money order payable to "Clerk, U.S. District Court"). However, if you qualify, you may be allowed to proceed without prepaying the filing fee. If you feel you cannot afford to pay the fee, complete the Application to Proceed Without Prepayment of Fees and Affidavit form and submit it to the Clerk of Court, who will submit your application to the Court for a ruling. If you are allowed to proceed without prepayment of fees, your complaint will be filed. If your application is denied, you must pay your filing fee before your complaint will be filed. Be sure to complete this form, answering all questions in detail, or it will be returned to you for completion. CIVIL COVER SHEET This form's purpose is to give the Court an overview of the basis for your civil action. Please complete each box as it applies to your case and submit the original to the Court with the complaint, summons, and Application to Proceed In Forma Pauperis (if applicable). SCREENING If your application to proceed without prepayment of fees is granted, your complaint will be screened to determine if it is frivolous, malicious, fails to state a claim upon which relief can be granted, or seeks relief against a defendant who is immune from such relief. If it is determined that your complaint is frivolous, malicious, fails to state a claim upon which relief can be granted, or seeks relief against a defendant who is immune from such relief, your complaint will be dismissed and the summons will not be issued. SERVICE OF THE SUMMONS AND COMPLAINT If you pay the required filing fee and file your complaint with the Clerk's Office (Clerk) , the summons will be issued (signed and sealed by the Clerk). You must arrange for SERVICE of the summons and complaint on each defendant in the case. You must have the defendant(s) served in accordance with Rule 4 of the Federal Rules of Civil Procedure. Once you have served the defendant(s), you must file with the Clerk proof of service using the Return of Service section of the summons form. After completing the complaint and all applicable forms, proofread them to ensure compliance with all instructions. Return the completed forms and the correct number of copies to the appropriate point of holding court: Clerk, U.S. District Court PO Box 2857 Clarksburg, WV 26302 Clerk, U.S. District Court 217 W. King St., Room 102 Martinsburg, WV 25401 Clerk, U.S. District Court PO Box 471 Wheeling, WV 26003 Clerk, U.S. District Court PO Box 1518 Elkins, WV 26241

FILING DOCUMENTS AFTER SERVICE HAS BEEN ISSUED Documents filed with the Clerk of Court after the service has been issued on the defendants must be filed with the Court in writing in the form of a pleading, e. g.: motion, notice, memorandum, etcetera. You must serve the defendant(s) or defense counsel with a copy of every pleading, letter, or other document submitted for consideration by the Court. The original of all documents filed with the Clerk should have a "Certificate of Service" (attached). Any pleading or other document submitted to the Clerk of Court for filing which does not bear a proper Certificate of Service may be returned to the submitting party. All instruments (pleadings, letters, motions, or other documents) pertaining to your case must be signed by all plaintiffs and must state the civil action number (case number). All documents and correspondence submitted to the Clerk of Court should be on letter-sized paper (8 ½ x 11 inches). Please do not use legal-size ( 8 ½ x 14 inches) paper. Always submit two additional copies with the original of any document to the Clerk of Court for its files.

IMPORTANT ADDITIONAL INFORMATION 1. IF YOU DO NOT KEEP THE COURT ADVISED OF YOUR CURRENT ADDRESS, YOUR CASE MAY BE DISMISSED FOR WANT OF PROSECUTION. It is improper to communicate directly with Judges or Magistrate Judges concerning matters that may become a subject in their Court. It is improper for the Clerk, Judges, or Magistrate Judges to give legal advice to litigants.

2.

3.

Thank you in advance for your cooperation regarding these instructions.

AT THE DIRECTION OF THE COURT Wally Edgell, Ph.D., Clerk UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA

(The following is a guide for preparing your complaint)
United States District Court 3 Northern District of West Virginia

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA

Plaintiff, v.

COMPLAINT CIVIL ACTION NO. ________________

Defendant(s)

Paragraph 1: Jurisdiction

Paragraph 2, etc. : Short and plain statement of the claim showing that the pleader is entitled to relief.

Final paragraph: Demand for judgment for the relief to which the party deems himself entitled. _______________________________ Plaintiff, Pro Se __________________ Date NOTE: This form is ONLY A GUIDE; do NOT fill it in. Use a plain sheet of 8 ½ x 11 inch paper and set up your complaint in this format. In Paragraph 1, state the reason that you believe the Federal Court has jurisdiction of the matter about which you are filing your complaint. In paragraph 2, state the problem or the thing about which you are complaining and why you think you are entitled to relief or redress. In the last paragraph, state the amount of damages or the kind of relief to which you think you are entitled. Please type or legibly hand write your complaint. Do not use a pencil to hand write your complaint. DOUBLE-SPACE your complaint, and submit the original and two copies to the Clerk of Court, plus one additional copy for each defendant to be served.

United States District Court

4

Northern District of West Virginia

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA

Plaintiff, v. Civil Action No.:_________________

Defendant(s)

Certificate of Service
I, (your name here), appearing pro se, hereby certify that I have served the foregoing (title of document being sent) upon the defendant(s) by depositing true copies of the same in the United States mail, postage prepaid, upon the following counsel of record for the defendant(s) on (insert date here):

(List name and address of counsel for defendant(s))

____________________________ (sign your name)

United States District Court

5

Northern District of West Virginia

United States District Court Northern District of West Virginia NOTICE, CONSENT, AND ORDER OF REFERENCE EXERCISE OF JURISDICTION BY A UNITED STATES MAGISTRATE JUDGE

Plaintiff, v. Case Number:

Defendant. NOTICE OF AVAILABILITY OF A UNITED STATES MAGISTRATE JUDGE TO EXERCISE JURISDICTION Pursuant to 28 U.S.C. §636(c), and Fed. R. Civ. P. 73, you are notified that a United States magistrate judge of this district court is available to conduct any or all proceedings in this case including a jury or non-jury trial, and to order the entry of a final judgment. Exercise of this jurisdiction by a magistrate judge is, however, permitted only if all parties voluntarily consent. You may, without adverse substantive consequences, withhold your consent, but this will prevent the Court's jurisdiction from being exercised by a magistrate judge. If any party withholds consent, the identity of the parties consenting or withholding consent will not be communicated to any magistrate judge or to the district judge to whom the case has been assigned. Any appeal from a judgment entered by a magistrate judge shall be taken directly to the United States Court of Appeals for the Fourth Circuit in the same manner as an appeal from any other judgment of this district court. CONSENT TO THE EXERCISE OF JURISDICTION BY A UNITED STATES MAGISTRATE JUDGE In accordance with provisions of 28 U.S.C. §636(c), and Fed. R. Civ. P. 73, the parties in this case consent to have a United States magistrate judge conduct any and all proceedings in this case, including the trial, order the entry of a final judgment, and conduct all postjudgment proceedings. Party Represented ______________________________ ______________________________ ______________________________ ______________________________ Signatures _____________________________ _____________________________ _____________________________ _____________________________ Date _________________ _________________ _________________ _________________

ORDER OF REFERENCE IT IS ORDERED that this case be referred to ____________________________United States Magistrate Judge, to conduct all proceedings and order the entry of judgment in accordance with 28 U.S.C. §636(c), and Fed. R. Civ. P. 73.

Date

United States District Judge

NOTE: RETURN THIS FORM TO THE CLERK OF COURT ONLY IF ALL PARTIES HAVE CONSENTED ON THIS FORM TO THE EXERCISE OF JURISDICTION BY A UNITED STATES MAGISTRATE JUDGE.

United States District Court

6

Northern District of West Virginia

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA

_____________________________________ _____________________________________, v. Civil Action No.:_________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ Certificate of Service I, (your name here), appearing pro se, hereby certify that I have served the foregoing (title of document being sent) upon the defendant(s) by depositing true copies of the same in the United States mail, postage prepaid, upon the following counsel of record for the defendant(s) on (insert date here):

(List name and address of counsel for defendant(s))

____________________________ (sign your name)

United States District Court

7

Northern District of West Virginia

UNITED STATES DISTRICT COURT Northern District of West Virginia
_________________________ Plaintiff, V. CASE NUMBER: _________________________ Defendant. APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT

YOU MUST COMPLETE THIS FORM FOR YOU, YOUR SPOUSE AND ALL PERSONS OVER 18 LIVING IN THE RESIDENCE WHERE YOU LIVE
Affidavit in Support of Motion I swear or affirm under penalty of perjury that, because of my poverty, I cannot prepay the docket fees of my action or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United States laws that my answers on this form are true and correct (28 U.S.C. § 1746; 18 U.S.C. § 1621.) Signed: ____________________________ 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 in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case's docket number, and the question number.

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 amount, that is amounts before any deductions for taxes or otherwise. Income Source Average Monthly Amount during the past 12 months You Employment Self-Employment Income from real property (such as rental income) Interest and dividends Gifts $ $ Spouse $ $ Other Adult* $ $ Amount expected next month

You $ $

Spouse $ $

Other Adult* $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

* Other adult living where you reside

-1-

Alimony Child Support

$ $

$ $

$ $

$ $

$ $

$ $

Retirement (social security, pensions, annuities, insurance, etc.) $ Disability (social security, insurance payments, etc.) Unemployment payments Public-Assistance (such as welfare) Other (specify):

$

$

$

$

$

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

Total monthly income: $

2. List your employment history with most recent employer first (Gross monthly pay is before taxes or other deductions). Employer Address Dates of Employment Gross Monthly Pay

_______________ _______________ _______________

_______________ _______________ _______________

_______________ _______________ _______________

_______________ _______________ _______________

3. List your spouse's employment history with most recent employer first (Gross monthly pay is before taxes or other deductions).

_______________ _______________ _______________

_______________ _______________ _______________

_______________ _______________ _______________

_______________ _______________ _______________

4. How much cash do you and your spouses 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 your spouse has $ $ $

Amount other adult 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.

* Other adult living where you reside

-2-

5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. Home (Value) Other real estate (Value) Motor vehicle #1 Make & year: (Value)

Model:

Registration #:

Motor vehicle #2 Make & year: Model: Registration #:

(Value)

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 spouse money Amount owed to you Amount owed to your spouse money

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

Age

8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semi-annually or annually to show the monthly rate. You Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxed included? ~ Yes Is property insurance included? ~ Yes $ ~ No ~ No $ Your Spouse Other adult* $

Utilities (electricity, heating fuel, water, sewer, and telephone) $ Home maintenance (repairs and upkeep) Food Clothing Laundry and dry cleaning * Other adult living where you reside $ $ $ $

$ $ $ $ $

$ $ $ $ $

-3-

Medical and dental expenses Transportation (not including motor vehicle payment) 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 other Regular expenses for operation of business, profession, or farm (attach detailed statement 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 the next 12 months? ~ Yes ~ No If yes, describe on an attached sheet

-4-

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 money for 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 docket fees for your appeal.

-5-

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) PTF Citizen of This State ' 1 DEF ' 1 and One Box for Defendant) PTF DEF Incorporated or Principal Place ' 4 '4 of Business In This State Incorporated and Principal Place of Business In Another State Foreign Nation

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

'2

U.S. Government Defendant

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

Citizen of Another State

' 2 ' 3

' 2 ' 3

' 5 ' 6

' 5 ' 6

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

' 2

(Place an "X" in One Box Only)

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

' 3

'4

' 5

' 7

Appeal to District Judge from Magistrate Judgment

VI. CAUSE OF ACTION

Brief description of cause: DEMAND $ CHECK YES only if demanded in complaint: ' Yes ' No JURY DEMAND: DOCKET NUMBER

' 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

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.

AO 440 (Rev. 8/01) | WVND (02/07) Summons in a Civil Action

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF WEST VIRGINIA
AT

V.

SUMMONS IN A CIVIL CASE CIVIL ACTION NO.

TO [Name and address of defendant]:

YOU ARE HEREBY SUMMONED and required to serve on [Name and address of Attorney(s) for Plaintiff(s)]:

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.

Wally Edgell, Ph.D., CLERK OF COURT
BY: ______________________________ DEPUTY CLERK

DATE: _________________________

AO 440 (Rev. 8/01) | SDWV/CIV-004 (4/05) Summons in a Civil Action

RETURN OF SERVICE
Service of the Summons and complaint was made by me(1)
NAME OF SERVER (PRINT) DATE TITLE

Check one box below to indicate appropriate method of service

G Served personally upon the defendant. Place where served: G Left copies thereof at the defendant's dwelling house or usual place of abode with a person of suitable age and
discretion then residing therein. Name of person with whom the summons and complaint were left:

G Returned unexecuted:

G Other (specify):

STATEMENT OF SERVICE FEES
TRAVEL SERVICES TOTAL

DECLARATION OF SERVER
I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service and Statement of Service Fees is true and correct.
Executed on
Date Signature of Server

Address of Server

(1) As to who may serve a summons see Rule 4 of the Federal Rules of Civil Procedure.