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UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI DIVISION
) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) COMPLAINT I. State the grounds for filing this case is Federal Court (include federal statutes and/or U.S. Constitutional provisions, if you know them):

(Enter above the full name of the Plaintiff[s] in this action.)

- vs -

Case No. (To be assigned by Clerk of District Court)

(Enter above the full name of ALL Defendant[s] in this action. Fed. R. Civ. P. 10(a) requires that the caption of the complaint include the names of all the parties. Merely listing one party and "et al." is insufficient. Please attach additional sheets if necessary.

II.

Plaintiff, , street address , state zip code , telephone number city . ,

resides at , county

(if more than one plaintiff, provide the same information for each plaintiff below)

III.

Defendant, , street address , state zip code .

lives at, or its business is located at , city county ,

(if more than one defendant, provide the same information for each defendant below)

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IV.

Statement of claim (State as briefly as possible the facts of your case. Describe how each defendant is involved. You must state exactly what each defendant personally did, or failed to do, which resulted in harm to you. Include also the names of other persons involved, dates, and places. Be as specific as possible. You may use additional paper if necessary):

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V.

Relief: State briefly and exactly what you want the Court to do for you.

VI.

MONEY DAMAGES: A) Do you claim either actual or punitive monetary damages for the acts alleged in this complaint? YES B) NO

If your answer to "A" is YES, state below the amount claimed and the reason or reasons you believe you are entitled to recover such money damages:

VII.

Do you maintain that the wrongs alleged in the complaint are continuing to occur at the present time? YES NO

I declare under penalty of perjury that the foregoing is true and correct. Signed this day of , 20

Signature of Plaintiff(s) 4