UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

_________________________________ _________________________________ _________________________________ (Enter above the full name of plaintiff in this action) v. _________________________________ _________________________________ _________________________________ _________________________________ (Enter above the full name of the defendant(s) in this action)

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CIVIL CASE NO: _________________ (to be supplied by Clerk of the District Court)

COMPLAINT

1. The plaintiff _________________________________________ a citizen of the County of

___________________________________________ State of Pennsylvania, residing at

__________________________________________________ wishes to file a complaint under

____________________________________________
(give Title No. etc.)

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2. The defendant is ______________________________________________________

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3. STATEMENT OF CLAIM: (State below the facts of your case. If you have paper

exhibits that give further information of your case, attach them to this completed

form. Use as much space as you need. (Attach extra sheet(s) if necessary)

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4. WHEREFORE, plaintiff prays that _________________________________________

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_______________________________ (Signature of Plaintiff)