UNITED STATES DISTRICT COURT

________________ DISTRICT OF ______________

Office of the Clerk of Court

The following instructions have been compiled to assist any person wishing to file a complaint in this court. We have attempted to simplify procedures; however, we cannot and will not act as lawyers nor give advice as counsel. We do not anticipate that these simple procedures will satisfy all needs, and the Local Rules of Practice for the U.S. District Court are available for more specific guidance. You should use the Local Rules along with the Federal Rules of Civil Procedures. The Federal Rules are available at a public library and the Local Rules are available from the Clerk's Office.

Appellee's Brief. The appellee's brief must conform to the requirements of Rule 28(a)(1)-(9) and (11).

(1) the jurisdictional statement;

(2) the statement of the issues;

(3) the statement of the case;

(4) the statement of the facts; and

(5) the statement of the standard of review.

(c) Reply Brief. The appellant may file a brief in reply to the appellee's brief. Amended pleadings, must be done in the same exact manner, and must be in a timely fashion.

A reply brief must contain a table of contents, with page references, and a table of authorities-cases (alphabetically arranged), statutes, and other authorities with references to the pages of the reply brief where they are cited.

(d) References to Parties. In briefs and at oral

argument, counsel should minimize use of the terms

"appellant" and "appellee." To make briefs clear,

counsel should use the parties' actual names or the

designations used in the lower court or agency

proceeding, or such descriptive terms as "the

employee," "the injured person," "the taxpayer," "the

ship," "the stevedore."

(e) References to the Record. References to the parts

of the record contained in the appendix filed with the

appellant's brief must be to the pages of the

appendix. If the appendix is prepared after the briefs

are filed, a party referring to the record must follow

one of the methods detailed in Rule 30(c). If the

original record is used under Rule 30(f) and is not

consecutively paginated, or if the brief refers to an

unreproduced part of the record, any reference must be

to the page of the original document. For example:

Only clear abbreviations may be used. A party

referring to evidence whose admissibility is in

controversy must cite the pages of the appendix or of

the transcript at which the evidence was identified,

offered, and received or rejected.

*********

If you believe that you have been injured or wronged

by someone, some individual, corporation or

government agency and you also believe you should be

compensated for the harm you have suffered, you may

decide to file a civil suit in the United States

District Court, without the help of an attorney.

FUNDAMENTAL INFORMATION

First, there are a few simple concepts you must get to

know and understand.

The PLAINTIFF is the person who files the lawsuit.

The DEFENDANT is the person who is being sued.

If you are representing yourself without the benefit

of an attorney, you are known as a PRO SE

LITIGANT. "Pro Se" is a Latin term meaning "for

yourself."

As a pro se litigant, you enjoy every right entitled

to you under the law. You need not worry if you

have had little or no experience with the courts

before. However, pro se litigants are expected to

follow/abide by

the rules that govern the practice of law in the

Federal Courts. Pro Se Litigants should be familiar

with the Federal

Rules of Civil Procedure and the Local Rilles of this

court.

FEDERAL COURT vs STATE COURT

There is a difference between State Court and Federal

Court. The difference being in what 1ypes of cases

(law suits) they can decide. This is called

JURISDICTION. State Court has

general/broadjurisdiction and Federal

Court has limited/specific jurisdiction. Under Federal

Court jurisdiction, the two main 1ypes of cases are

Federal

Question Cases and Diversity Cases.

FEDERAL QUESTION CASES: are cases where the issue

involves violation of Federal Law.

DIVERSITY CASES:

are cases where the Plaintiff and Defendant are

citizens of different states and the amount in

controversy exceeds the sum or value of $75,000.

exclusive of interest and costs.

STEP ONE: WRITE YOUR COMPLAINT

All cases are comprised of documents prepared and

filed by litigants. The most common documents are

the complaint, answer and motions. The first document

that you must write/file is called a COMPLAINT (see

Attachment No.1).

The function of the COMPLAINT is to tell the Court and

the defendant the reason for filing the lawsuit and

what relief you desire. You must provide an original

and one of the complaint. along with sufficient copies

for each defendant to be served. The COMPLAINT must

state:

The NAME AND ADDRESS of the plaintiff in the upper

left hand comer of the complaint. The names of all the

plaintiffs and defendants must be stated in the

caption. The Court will provide the case number.

The JURISDICTION or reason your case is being filed in

Federal Court. See 28 D.S.C. § 1331et seq.

The ALLEGATIONS or claims that you are making against

the defendant(s). Place each allegation in a short

clearly-written paragraph. See Rule 10 Federal Rules

of Civil Procedure.

The RELIEF you are seeking from the court. This can be

money or something you want the Judge to make the

defendant do or stop doing. This information is

usually written in the last paragraph of the

COMPLAINT.

If you believe that you are entitled to a trial by

jury, you must indicate in a paragraph following the

relief requested that you claim trial by jury. See

Rule 38(b) of the Federal Rules of Civil Procedure.

Do not worry that your COMPLAINT is not professionally

written. It should be typed if possible. The Court

will take into consideration that you are a PRO SE

litigant and untrained in drafting legal documents.

You should, however, make every effort to state your

case in clear, concise terms. See Rule_8 and 10 of the

Federal

Rules of Civil Procedure. YOU MUST SIGN YOUR

COMPLAINT.

Forms for filing a petition under Title 28 D.S.C. &

2254 for writ of habeas corpus by a person in state

custody or a motion under Title 28 D.S.C. § 2255 to

vacate, set aside, or correct sentence by a person in

Federal custody are available from the Clerk's Office.

All pleadings submitted to this Court must be on 8 ½

by 11" paper.

STEP TWO: FILE YOUR COMPLAINT

Your next step is to file the COMPLAINT with the

Court. In addition to filing the COMPLAINT the

following forms will have to be completed and

submitted with the complaint:

1.

A Civil Cover Sheet - (Attachment 2)

2.

If you are making service by SUMMONS, a completed

SUMMONS for each defendant - (Attachment 3) Please

refer to Step 3 for service.

3.

A $150.00 file fee for a civil case (the filing fee

for a petition for writ of habeas corpus is $5.00) The

filing fee may be waived if you cannot afford to pay

it. For more information, see below. All checks or

money orders should be made payable to: "CLERK, UNITED

STATES DISTRICT COURT".

IF YOU CANNOT AFFORD TO PAY THE FILING FEE you may be

allowed to have the filing fee waived if you fill out

an APPLICATION FOR LEA VB TO PROCEED IN FORMA PAUPERIS

(Attachment 4)

and send it to the Court with the COMPLAINT, Cover

Sheet, service copies for each defendant and, if

appropriate, completed Summons forms. The Financial

Affidavit is required to be completed so that the

selected Judge can make a determination of your

inability to pay the filing fee.

When you file the COMPLAINT, Cover Sheet (summons if

applicable) and Application for Leave to Proceed in

Forma Paupers, each of these will be reviewed and

forwarded to a Judge for consideration. If your

Application is approved, the filing fee will be waived

and your case will proceed. If your Application is not

approved, you must pay the filing fee to have your

case proceed.

If your In Forma Paupers application is granted, the

Court will direct the U.S. Marshal to serve your

summons and complaint upon the defendants. In order

for the Marshal to effectuate service on all

defendants, you must provide service copies of the

complaint for each defendant and complete a Marshal's

285 form for each defendant. You are responsible for

the movement of your case once it is filed.

CONSENT FORMS

When you file your complaint you will be given forms

called: NOTICE OF RIGHT TO CONSENT TO THE EXERCISE OF

CIVIL JURISDICTION BY A MAGISTRATE JUDGE AND APPEAL

OPTION and CONSENT TO PROCEED BEFORE UNITED MAGISTRATE

JUDGE, which you will need to serve on the parties in

your case. Upon the voluntary consent of ALL parties

(who must file the consent form with the Court), a

Magistrate Judge may conduct any and all proceedings

in your civil case, including a jury or non-jury

trial, and the entry of final judgment, in accordance

with the provisions of Title 28, U.S.C. § 636(c).

STEP THREE: SERVICE OF PROCESS

If you are NOT preceding In Forma Paupers, your next

step is to SERVE (inform) each of the defendants that

he or she is being sued. This may be done in two ways:

NOTICE AND REQUEST FOR WAIVER OF SERVICE

If you are suing the United States (and its agencies,

corporations, or officers) or a state, local or

foreign government, you CANNOT use this method and you

MUST arrange for Service of Process (described below

at number 2).

You may notify non-government defendant(s) of the

commencement of the lawsuit

by sending a "NOTICE OF LAWSUIT AND REQUEST FOR WAIVER

OF SERVICE OF SUMMONS" - Form AO 398 (Attachment 5)

along with a copy of the complaint by first-class mail

or other reliable means. You must also include a copy

of the WAIVER OF SERVICE OF SUMMONS- Form AO 399

(Attachment 6) and a self-addressed return envelope.

See Rule 4(d) of the Federal Rules of Civil Procedure.

If service is waived by the defendant the Waiver of

Service form is returned to the plaintiff for filing

with the court and the action shall proceed. If the

defendant does not waive service, the plaintiff must

proceed with service of process.

SERVICE OF PROCESS

Making "service of process" involves serving a copy of

the complaint upon each of the defendants.

A SUMMONS is a writ used to notify the person named as

the defendant of the commencement of the civil action

and the requirement to appear and answer. The summons

must contain the name of the court and the names of

the parties, be directed to the defendant, state the

name and address of the plaintiff's attorney, if any,

otherwise the plaintiff's address and the time within

which the rules require the defendant to answer the

complaint.

If a defendant has not "waived service of summons" OR

you are suing a government (federal, state, local,

foreign) you MUST arrange to have a copy of an

original summons and a copy of the complaint served

upon each defendant.

You must complete a summons for each defendant and

present each summons to the Clerk who will sign and

place the Court Seal on each summons. A copy of the

summons must be served upon each defendant with a copy

of the complaint. The original summons is for the use

of the person making service.

You can make service of process by having a

"disinterested" (non-party) person who is over the age

of eighteen deliver copies of the SUMMONS and

COMPLAINT to each of the defendants. When using this

method of making service of process, have the server

fill out the back of the original SUMMONS and send it

to the Court. See Rule 4.> Federal Rules of Civil

Procedure.

NOTE: Service of the COMPLAINT on the defendant must

be made within 120 days from the date the complaint

was filed or the case will be subject to dismissal.

See Rule 4 Federal Rules of Civil Procedure.

THINGS YOU SHOULD KNOW ABOUT

The ANSWER is the formal written statement by the

defendant responding to a complaint setting forth any

defenses and objections to the claims by the

plaintiff.

A MOTION is an application or request made to the

court for the purpose of obtaining a ruling or order

directing some act to be done in favor of the

applicant. See Rule 7(b). Federal Rules of Civil

Procedure.

AFTER THE ANSWER

In most cases the Court will issue a SCHEDULING ORDER

which sets forth a timetable with deadlines the

litigants must follow.

The DISCOVERY PERIOD is the time frame allowed by the

Court for both plaintiff and defendant to discover

facts, research the law, and gather evidence to be

presented at trial to prove the litigant's

position/case.

The discovery period always comes after the filing of

the answer by the defendant and before the first day

of the trial.

COMPLAINT/ANSWERIDISCOVERY PERIODITRIAL

Whenever you file any document with the Court, you

must always:

Send a copy to each of the parties who are involved in

the case, or their lawyers, and indicate on a Proof of

Service form (see attachment 7) at the end of the

document that you have done so in accordance with

Federal Rule of Civil Procedure.

Provide the correct civil action number of your case

on ALL documents and correspondence and have it

readily available whenever you call the Court for

information.

Sign all documents you file with the Court. Place the

words "SUI JURIS" after your name. Place your address

and telephone number on all documents and inform the

Court of any changes, as soon as possible to ensure

proper service of Court issued orders. It is very

important that you provide a telephone number in the

event it is necessary to obtain further information or

clarification or advise you of any changes in hearing

schedules.

INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER

SHEET FORM

Authority For Civil Cover Sheet

The civil cover sheet and the information contained

herein neither replaces nor supplements the filings

and service of pleading or other papers as require< 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, 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, us!

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 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, notin! 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" il

one of the boxes. I f there is more than one basis of

jurisdiction, precedence is given in the order shown

below.

United States plaintiff. (I) Jurisdiction based on 28

U.S.C. J 345 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 0 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

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 IV below, ii

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

petitior for removal is granted, check this box.

Remanded fr0111 Appellate Court. (3) Check this box

for eases 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 l1

multidistrict case is transferred into the district

under authority of Title 28 U.S.C. Section 1407. When

the 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 civi I statute

directly related to the cause of action and give a

brief description of the cause.

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. [n 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 number

and the corresponding judge names for such cases.

Date and Attorney Signature. Date and sign the civil

cover sheet.

CIVIL COVER SHEET

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF STATE ______________

_____________ DIVISION

Cause No.: _________________________________

Name ________ individually, and )

on behalf of all persons similarly situated, )

)

Plaintiffs-Petitioners, )

)

v. )

)

STATE OF ____________ )

)

Defendant-Respondent. )

Verified Complaints for Patterns of: Denials and

Violations of Civil Rights, Neglect to Prevent the

Same, Willful Discrimination, Policy of Clear

Constitutional Rights, and Reckless or Negligent

Government Mismanagement; and, Verified Petition for

Damages and Certain Remedial Actions

Your Name________

In Propria Persona, Sui Juris

A Free Man, Sovereign, Constitutional Rights Intact &

no rights are waived at any time.

Address

Address

zip code exempt

"Telephone Appearance"

(tele)phone

I Declare for under Penalty of Perjury and under the

Constitution in the State of __________ That the for

Going is True and Correct.

06[IV. NATURE OF SUIT (Place an "X" in One Box Only)

CONTRACT TORTS

0 110 Insurance PERSONAL IN.JURY PERSONAL INJURY

0 120 Marine 0 310 Airplane 0 362 Personal Injury-

0 130 Miller Act 0 315 Airplane Product Med.

ylalpractice

0 140 Negotiable InstrUment Liability 0 365 Personal

Injury -

0 150 Recovery ofOverpaymem 0 320 Assault. Libel &

Product Liability

& Enforcement of Judgment Slander 0 368 Asbestos

Personal

0 151 Medicare Act 0 330 Federal Employers' InjlllY

Product

0 152 Recovery of Defaulted Liability Liability

Student Loans 0 340 Marine PERSONAL PROPERTY

(Exc!. Veterans) 0 345 Marine Product 0 370 Other

Fraud

0 153 Recovery of Overpayment Liability 0 371 Tmth in

Lending

ofVeteran.s Benetlts 0 350 Motor Vehicle 0 380 Other

Personal

0 160 Stockholders' Suits 0 355 Motor Vehicle Property

Damage

0 190 Other Contract Product Liability 0 385 Property

Damage

0 195 Contract Product Liability 0 360 Other Personal

Injury Product Liability

0 210 Land CondenU1ation 0 441 Voting 0 510 ylotions

to Vacate

442 Employment

0 230 Rem Lease & Ejectment 0 443 Housing/ Habeas

Corpus:

0 240 Tons to Land Accommodations 0 530 General

0 245 Tort Product Liability 0 444 Welfare 0 535 Death

Penalty

0 290 All Other Real Property 0 440 Other Civil Rights

0 540 Mandamus & Other

0 550 Civil Rights

0 555 Prison Condition

FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES

0 610 Agriculture 0 422 Appeal 28 USC 158 0 400 State

Reapportionment

0 620 Other Food & Dmg 0 410 Antitrust

0 625 Dmg Related Seizure 0 423 Withdrawal 0 430 Banks

and Banking

of Property 21 USC 881 28 USC 157 0 450

ConlTnerce!ICC Rates!et

0 630 Liquor Laws 0 460 Deportation

0 640 R.R. & Truck PROPERTY RIGHTS 0 470 Racketeer

Intluenced alll

0 650 Airline Regs. 0 820 Copyrights COlTtlpt

Orgamzations

0 660 Occupational 0 830 PalCm 0 810 Selective Service

Safety/Health 0 850 Securities/Commodities/

0 690 Other Exchange

0 875 Customer ChaHenge

LABOR SOCIAL SECURITY 12 USC 3410

0 710 Fair Labor Standards 0 861 HIA (1395 ff) 0 891

Agricultural Acts

Act 0 862 Black Lung (923) 0 892 Economic

Stabilization I

0 no Labor/Mgmt. Relations 0 863 DIWCIDIWW (405(g» 0

893 Environmental Mailers

0 894 Energy Aliccalion Act

0 895 Freedom of

0 730 Labor/Mgmt.Reporting 0 865 RSI (405(g)

Infonnalion Act

& Disclosure Act 0 900Appeal of Fee

0 FEDERAL TAX SUITS Deten1\ination Under

Equal Access to Justice

0 870 Taxes (U.S. Plaimiff

0 790 Other Labor Litigation

0 791 Emp!. Ret. Inc. State Statutes

Security Act 0 87l IRS-Third Party 0 890 Other

Statutory Actions

26 USC 7609

V. ORIGIN (PLACE AN "X" IN ONE BOX ONL Y)

0 I Original 0 2 Removed from 0 3 Remanded from 0 4

Reinstated 0 5 TransfelTed _rom

Proceeding State Court Appellate Court or another

dlstnct

Reopened (speclfv)

(Cite the U.S. Ch'il Statute under which you are

filing and write brief statement of cause.

Do not cite jurisdictional statutes unless diversity.)

0 6 Multidistrict Litigation

7 Appeal to Distl

0 Jud£e Irom

Magistrate

.Judgment

VI. CAUSE OF ACTION

VII. REQUESTED IN

COMPLAINT:

VIII. RELATED CASE(S)

IF ANT

0CHECK IF THIS IS A CLASS ACTION UNDER F.R.C.P. 23

DEMAND $

CHECK YES only if demanded in complaint: JURY DEMAND:

0 Yes 0 No

(See instructions): JUDGE

DOCKET NUMBER

DATE

SIGNA TURE OF ATTORNEY OF RECORD

FOR OFFICE: USE ONL Y

RECEIPT 1#

AMOUNT

APPLYING IFP

JUDGE

MAG. JUDGE

RETURN OF SERVICE

DATE

Service of the Summons and complaint was made by me\l)

NAME OF SERVER (PRINT) TITLE

Check one box belo'w to indicate aDDrOlJriate method

or service

D Served personally upon the defendant. Place where

served:

0 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:

D Retumed unexecuted:

STATEMENT OF SERVICE FEES

TRA VEL I SERVICES TroTAL

DECLARATION OF SERVER

I declare under penalty of perjury under the laws of

the United States of America that the foregoing

infonllation

contained in the Retunl of Service and Statement of

Service Fees is true and COtTect.

Executed on

Date Signa/lire of Server

Address afServer

t,

(I) As to who may serve a summons see Rule 4 of the

Federal Rules of Civil Procedure.

%AO 240 (Rev. 9/96)

UNITED STATES DISTRlCT COURT

District of

Plaintiff

APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND

AFFIDAVIT

v.

CASE NUMBER:

Defendant

I,

declare that I am the (check appropriate box)

0 petitioner/plaintiff/movant 0 other

in the above-entitled proceeding; that in support of

my request to proceed without prepayment of fees or

costs

under 28 use § 1915 I declare that I am unable to pay

the costs of these proceedings and that I am entitled

to the relief sought in the complaint/petition/motion.

In support of this application, I answer the following

questions under penalty of perjury:

1.

Are you currently incarcerated?

0 Yes

ONo

(If "No," go to Part 2)

If "Yes," state the place of your incarceration

Are you employed at the institution? Do you receive

any payment from the

Attach a ledger sheet from the institution(s) of your

incarceration showing at least the past six months'

transactions.

2.

Are you currently employed?

0 Yes

ONo

a.

If the answer is "Yes," state the amount of your

take-home salary or wages and pay period and give the

name and address of your employer.

b.

If the answer is "No," state the date of your last

employment, the amount of your take-home salary or

wages and pay period and the name and address of your

last employer.

3.

In the past 12 twelve months have you received any

money from any of the following sources?

a. Business, profession or other self-employment 0 Yes

ONo

b. Rent payments, interest or dividends 0 Yes ONo

c. Pensions, annuities or life insurance payments 0

Yes ONo

d. Disability or workers compensation payments 0 Yes

ONo

e. Gifts or inheritances 0 Yes ONo

f. Any other sources 0 Yes ONo

g. Social Security, is Exempt 0 Yes ONo

TITLE 42 > CHAPTER 7 > SUBCHAPTER XVI > Part B > §

1383

If the answer to any of the above is "Yes," describe,

on the following page, each source of money and state

the amount received and what you expect you will

continue to receive.

AO 240 Reverse (Rev. 9/96)

4.

Do you have any cash or checking or savings accounts?

0 Yes

ONo

If "Yes," state the total amount.

5.

Do you own any real estate, stocks, bonds, securities,

other financial instruments, automobiles or any other

thing of value? 0 Yes 0 No

If "Yes," describe the property and state its value.

6.

List the persons who are dependent on you for support,

state your relationship to each person and indicate

how much you contribute to their support.

I declare under penalty of perjury that the above

information is true and correct.

Signature of Applicant

Date

NOTICE TO PRISONER: A Prisoner seeking to proceed IFP

shall submit an affidavit stating all assets. In

addition, a prisoner 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.

NOTICE OF LA WSIDT AND REQUEST FOR WAIVER OF SERVICE

OF SUMMONS

TO:

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) and has been assigned docket number District of

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

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 cOUl1 to require

you (or the party on whose behalf you are addressed)

to pay the fun 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 fom1.

I affirm that this request is being sent to you on

behalf 0 f the plaintiff,

day of

this

Signature of Plaintiffs Attorney or Unrepresentative

Plaintiff

A-Name of individual defendant (or name of onicer or

agent of corporate defendant) B- Title, or other

relationship of individual to corporate defendant

C-Name of corporate defendant, if any

D-District

======================================================