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USDC IN/ND case 2:19-cv-00207 document 1 filed 05/31/19 page 1 of 11

UNITED STATES DISTRICT COURT


FOR THE NORTHERN DISTRICT OF INDIANA

DNA MOTOR, INC., A CALIFORNIA Case No.: 2:219-CV-207


CORPORATION,
Plaintiff,
COMPLAINT FOR:
vs.
1. PATENT INFRINGEMENT OF THE ‘741
E-MOTOR INDUSTRIES INTERNATIONAL S PATENT (35 U.S.C. § 271(a))
SHANGHAI CO., LTD, ALSO KNOWN AS E-
MOTOR USA, INC. AND/OR EMUSA 2. WILLFUL INFRINGEMENT OF THE ‘741
AUTOMOTIVE, S PATENT

Defendant. DEMAND FOR JURY TRIAL

COMPLAINT FOR WILLFUL PATENT INFRINGEMENT


AND DEMAND FOR JURY TRIAL

Plaintiff DNA MOTOR, INC., by and through the undersigned counsel, presents the

following allegations and facts in support of this Complaint and demands a jury trial on all

causes of action stated herein against the named Defendant as follows:

NATURE OF THE ACTION

1. This is a civil action for infringement of a patent, arising under the laws of the United

States relating to patents, including, without limitation, 35 U.S.C. § 101, et seq., 35 U.S.C. §271

and § 281. Plaintiff seeks monetary damages and exemplary damages including its costs and

attorney fees for Defendant’s willful infringement of United States Design Patent No. D763,741

S.

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JURISDICTION AND VENUE

2. This Court has subject matter jurisdiction over this case for patent infringement under

28 U.S.C. §§ 1331 and 1338 (a) and pursuant to the patent laws of the United States of America,

35 U.S.C. §101, et seq.

3. Venue properly lies within the Northern District of Indiana pursuant to 28 U.S.C. §§

1391(b) and (c); and 28 U.S.C. § 1400(a). Venue properly lies within the Northern District of

Indiana because Defendant is headquartered and has its principal place of business in the

Hammond Division of this District. In addition, on information and belief, Defendant conducts

substantial business directly and through third parties or agents in this judicial district by selling

and offering to sell the infringing products and by conducting other business in this judicial

district. Furthermore, Plaintiff has been harmed by the Defendant conducting business

transactions and sales in this District, and by online sales including but not limited to its sales

under the “speedyracer” assumed business name and through Defendant’s website

www.speedyracer.com.

4. This Court has personal jurisdiction over Defendant because Defendant is

headquartered and has its principal place of business in the Hammond Division of this District.

Defendant also transacts continuous and systematic business within the State of Indiana and the

Northern District of Indiana. In addition, this lawsuit arises out of Defendant’s infringing

activities, including, without limitation the making, using, selling and/or offering to sell

infringing products in the State of Indiana and the Northern District of Indiana.

5. Upon information and belief, certain of the products manufactured by or for Defendant

have been and/or are currently sold and/or offered for sale to consumers including, but not

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limited to, consumers located within the State of Indiana and online at, among other places,

Amazon, eBay, NewEgg.com, Walmart.com, and www.speedyracer.com.

PARTIES

6. Plaintiff DNA Motor, Inc. is a California corporation, with an office and principal

place of business located at 801 Sentous Avenue, City of Industry, California 91748.

7. Defendant E-Motor Industries International Shanghai Co., Ltd., also known as E-

Motor USA, Inc. and EMUSA Automotive, is a foreign for-profit corporation, which is

headquartered and has its principal place of business at 202 W. Ridge Road, Griffith, Indiana

46319. Defendant is registered to do business in Indiana through the Indiana Secretary of State,

and Defendant’s resident agent is its president, Xiaoyong Chen, who maintains an address in

Munster, Indiana, which is within this judicial District.

THE ACCUSED PRODUCTS

8. Defendant’s accused products, for purposes of the asserted patent, include Defendant’s

Front Lower Control Arms incorporating the patented designs found in United States Design

Patent No. D763,741 S (the Patented Design).

9. Plaintiff believes and thereupon alleges that Defendant is aware that its customers and

end-users are using the accused products in an infringing manner based on comments and

discussions posted on its website and other public websites where Defendant’s authorized agents,

customers and end-users discuss and disclose the use of the accused products.

10. Furthermore, on January 25, 2019, Plaintiff, via U.S. Mail and Email, notified

Defendant as to Plaintiff’s ownership right of the ‘741 S Patent, notified Defendant that the

manufacture and sales infringed the ‘741 S Patent, and demanded that Defendant cease and

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desist all infringing activities. A true and accurate copy of the January 25, 2019 letter is attached

as Exhibit A.

THE ASSERTED PATENT

11. On February 10, 2015, the United States Patent and Trademark office duly and

legally issued United States Design Patent No. D763,741 S, entitled “Set of Vehicle Control

Arms” (the ‘741 S Patent”). The patent’s named inventor is Jacky Chen, and Plaintiff DNA

Motor, Inc is the assignee and owner of the entire right, title and interest in and to the ‘741 S

Patent and vested with the right to bring this suit for damages and other relief. A true and correct

copy of the ‘741 S Patent is attached hereto as Exhibit B.

COUNT ONE
INFRINGEMENT OF THE ‘741 S PATENT BY DEFENDANT

12. Plaintiff re-alleges and incorporates by reference each of the allegations set forth in

paragraphs 1 through 11 above.

13. The ‘741 S Patent, a Design Patent, has one single claim directed to the ornamental

design for a set of vehicle control arms as shown below:

CLAIMS

WHAT IS CLAIMED IS:

The ornamental design for a set of VEHICLE CONTROL ARMS, as

shown and described.

14. Defendant has knowledge of its infringement of the ‘741 S Patent since at least its

receipt of the January 25, 2019 letter found at Exhibit A.

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15. Defendant copied the ornamental design for a set of vehicle control arms. A side by

side comparison of the ‘741 S patented design and exemplary specimens of Defendant’s

advertisements for ornamental control arms is shown below:

741 S patented design Defendants’ ornamental control arms

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(same picture as above)

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16. As shown in the pictures, the ornamental design for a set of vehicle control arms

advertised and offered for sale by Defendant is the same or substantially the same as the

ornamental design for a set of vehicle control arms of the ‘741 S Patent. The ornamental design

of the vehicle control arms, and each of them, are so similar as to be nearly identical such that an

ordinary observer, giving such attention as a purchaser usually gives, would be so deceived by

the substantial similarity between the designs so as to be induced to purchase Defendant’s

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products believing them to be substantially the same as the ornamental design for a set of control

arms protected by the ‘741 S Patent.

17. Plaintiff has not granted a license or any other authorization to the Defendant named

herein to make, use, offer for sale, sell or import ornamental vehicle control arms that embody

the ornamental design for control arm design patented in the ‘741 Patent and which is proprietary

to Plaintiff.

18. Plaintiff alleges upon information and belief that, without authority, Defendant has

infringed and continues to infringe the ‘741 S Patent by, inter alia, making, using, offering to sell

or selling in the United States, including the State of Indiana and within this District, products

infringing the ornamental design covered by the ‘741 S Patent in violation of 35 U.S.C. § 271

including but not limited to the ornamental designs herein identified.

19. Defendant’s ornamental design vehicle control arms infringe the ‘741 S Patent

because, inter alia, in the eye of the ordinary observer, giving such attention as a purchaser

usually gives, the ornamental design of the vehicle control arms of the ‘741 S Patent and the

ornamental design of the control arms of the products of Defendant are substantially the same,

with the resemblance being such as to deceive such an ordinary observer, inducing them to

purchase one supposing it to be the other.

20. Defendant’s acts of infringement of the ‘741 S Patent were undertaken without

authority, permission or license from Plaintiff. Defendant’s infringing activities described herein

violate 35 U.S.C. § 271.

21. Plaintiff is informed and believes the Defendant intentionally sells, ships or otherwise

delivers the accused products in the United States, with knowledge that the accused products are

designed to and do practice the infringing features of the ‘741 S Patent. On information and

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belief, these products are designed to implement the infringing features of the ‘741 S Patent.

Defendant offers the accused products for sale at its offices in this District, through its website

www.speedyracer.com, and through other websites such www.Ebay.com.

22. Defendant has confirmed its receipt of the January 25, 2019, and that it has no

intention of stopping its offers of sale and sales of the accused products. Thus, the infringement

of the asserted claims of the ‘741 S Patent is ongoing and will continue unless and until

Defendant is enjoined from further infringement by the Court.

COUNT TWO
WILLFUL INFRINGEMENT OF THE ASSERTED PATENT

23. Plaintiff re-alleges and incorporates by reference each of the allegations set forth in

paragraphs 1 through 22 above.

24. Defendant has manufactured, marketed, offered to sell, and sold products that infringe

Plaintiff’s ‘741 S Patent.

25. Defendant’s infringement of the ‘741 S Patent has been willful.

26. Defendant has had actual knowledge of the ‘741 S Patent and its infringement of the

‘741 S Patent since at least its receipt of the January 25, 2019 letter in January of 2019.

27. Plaintiff’s January 25, 2019 letter to Defendant, with the ‘741 S Patent attached

(Exhibit A), and Defendant’s continued marketing and sales evidence not only Defendant’s pre-

suit knowledge of the ‘741 S Patent, but that Defendant’s infringement of that patent has been,

and continues to be willful and deliberate, warranting treble damages and attorney fees.

PRAYER FOR RELIEF

WHEREFORE, Plaintiff prays for relief and judgment as follows:


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1. The determination that Defendant has infringed the ‘741 S Patent;

2. That Defendant and its officers, agents, servant, employees and attorneys, and those

persons in active concert or participation with it, be permanently enjoined from infringement of

the Patent-in-Suit, including but not limited to any making, using, offering for sale, selling or

importing or exporting of unlicensed infringing products within and without the United States;

3. Compensation for all damages caused by Defendant’s infringement of the Patent-in-

Suit, to be determined at trial;

4. Finding Defendant’s infringement of the ‘741 S Patent has been willful and therefore

enhancing Plaintiff’s damages up to three times the damages found or assessed by the jury

pursuant to 35 U.S.C. § 284;

5. A finding that this case is exceptional and granting an award of reasonable attorney

fees pursuant to 35 U.S.C. § 285;

6. Granting Plaintiff’s pre- and post-judgment interest on its damages, together with all

costs and expenses;

7. Ordering Defendant to deliver up and destroy all infringing products; and

8. Granting Plaintiff such other and further relief as the Court may deem just and proper.

JURY DEMAND

Plaintiff, by counsel, respectfully requests that this cause of action be set for trial by jury

on all claims so triable.

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Respectfully submitted,
/s/Patrick J. Olmstead, Jr.
Patrick J. Olmstead, Jr., Attorney No. 25369-49
Patrick Olmstead Law LLC
P.O. Box 1067
Greenwood, IN 46142
Telephone: (317) 884-8524
polmstead@patrickolmsteadlaw.com

Elizabeth Yang (CA SBN: 249713)*


Law & Mediation Offices of Elizabeth Yang
199 W. Garvey Ave., Suite 201
Monterey Park, CA 91754
Telephone: (877) 492-6452
Elizabeth@yanglawoffices.com

Attorneys for Plaintiff


DNA MOTOR, INC.

*Attorney Yang will be applying for pro hac vice


admission to this Court.

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EXHIBIT A
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January 25, 2019

Via U.S. Mail and Email Transmission

Speedyracer Performance
E-Motor US, Inc.
EMUSA Automotive
202 W. Ridge Rd.,
Griffith, IN 46319
5161 Commerce Dr.,
Baldwin Park, CA 91706
Email: sales@speedyracer.com

Re: DEMAND TO CEASE AND DESIST VIOLATIONS OF PATENT LAWS

To Whom It May Concern:

Please be advised that our firm has been retained by Mr. Jacky Chen, the owner of the
patent registration no. USD763,741S (hereinafter “the Subject Patent”) to represent his legal
interests going forward concerning your illicit and illegal conduct in infringing upon the Subject
Patent, a copy of which is attached hereto as Exhibit A.

Enclosed herein, as Exhibit B, is a collection of screenshots of web pages reflecting the


infringing products your company has been selling and/or offering to sell on Amazon.com,
Ebay.com, NewEgg.com, Walmart.com, and your company website, speedyracer.com, which is
not inclusive of all the infringing products but they all sell, offer to sell or induces others to use
or contribute to the performance of the claim of our client’s registered Patent, which specifically
discloses the invention a “the ornamental design for a set of vehicle control arms, as shown and
described” in Fig.1- Fig7 of Exhibit A.

A detailed review and comparison between my client’s patented design and your
company’s infringing products clearly reveal that your products are mere direct imitation of my
client’s patented design.

Moreover, although you have attempted to sell these infringing products under different
names or DBAs, we have confirmed that all the infringing products sold by the following sellers
are actually linked to your company:
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• Super speed world shop


• Super street parts
• Dxs auto parts
• 2xspeed
• mracing88
• boost masters
• Speedy racer

As such, your company’s conduct of improperly selling these infringe products, may
have constituted a violation of 35 U.S.C §271(a), either based upon literal infringement, or, in
the alternative, under the doctrine of equivalents. Under the patent laws, to the extent the Court
finds your infringement is willful, my client is still entitled up to three(3) times the amount of
actual damages. As well, under 15 U.S.C. §285, we, if needed, will also seek recovery of any and
all attorneys and cost of suits if we are forced to file an action against your company for willful
infringement.

This correspondence shall serve as our client’s formal demand that your company
immediately cease and desist from all sales of all the infringing products as identified herein by
your company, including those under your DBAs. We will consider any further sales of the
infringing product to be evidence of willful intent which will subject your company to the
heightened damages available in cases of willful infringement as stated.

Within four(4) days from the receipt of this letter please confirm that you have ceased
and desisted from the sale of the offending product infringing upon our client’s patented design.
At that time we also request that you properly produce all the documentation showing: (1) your
supplier of the infringing products, including but not limited to the company’s name, and the
contact person’s phone number and email address; (2) any and all remaining inventories in your
company or your warehouse; and (3) the total sales your company has made for these identified
infringing products and the accounting records thereof.

If you are interested in an informal settlement, we will only consider such proposal on the
condition that: (1) you fully complied with the demands as set forth herein above; (2) you turned
over any and all remaining inventory to my client; and (3) properly turn over any and all profits
made by your company by reason of selling these infringing products.

Should you fail or refuse to comply with this letter, our client will have no choice but to
file a complaint against your company seeking immediate injunctive relief, as well as
compensatory, statutory and punitive damages, attorneys’ fees and costs of suits.

If we do not receive any response by the stated deadline, we will move forward and file a
lawsuit against your company for the reasons stated hereinabove. Please be properly advised
that nothing set forth herein is intended to waive any rights, claims or cause of action on the part
of our client arising from this dispute.
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Please contact the undersigned directly if you have any questions.

Respectfully,

Attorneys

Law & Mediation Offices of Elizabeth Yang


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Exhibit A
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USOOD763741S

(12) United States Design Patent (10) Patent No.: US D763,741 S


Chen (45) Date of Patent: . Aug. 16, 2016

(54) SET OF VEHICLE CONTROL ARMS R s : '92. yester . . . . . . . . . . . . . . . . . . . . . . R.32


Oll . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D496,887 S * 10/2004 Carlson ........................ D12/159
(71) Applicant: Jacky Chen, City of Industry, CA (US) D543,492 S * 5/2007 Lyew ........................... D12/159
D545,246 S * 6/2007 Kroeker ....................... D12/159
(72) Inventor: Jacky Chen, City of Industry, CA (US) D716,193 S * 10/2014 Hsu .............................. D12/159
D727,218 S * 4/2015 Hsu .............................. D12/159
ck
(**) Term: 14 Years * cited by examiner
(21) Appl. No. 29/517,113 Primary Examiner — Michael A Pratt
1-1. (74) Attorney, Agent, or Firm — Che-Yang Chen; Law
(22) Filed: Feb. 10, 2015 Offices of Scott Warmuth
(51) LOC (10) Cl. ................................................ 12-16
(52) U.S. Cl. (57) CLAIM
USPC ......................................................... D12/159 The ornamental design for a set of vehicle control arms, as
(58) Field of Classification Search shown and described.
USPC ......................................................... D22/159 DESCRIPTION
CPC ............. B60G 7/001; B60G 2200/142: B60G
2200/1424; B60G 2200/154: B60G 2204/418: FIG. 1 is a perspective view of the set of vehicle control arms
B60G 2206/122; B60G 2206/16; B60G 3/20; showing my new design;
B60G 7/008 FIG. 2 is a front elevational view thereof
See application file for complete search history. FIG. 3 is a rear elevational view thereof;
FIG. 4 is a right side elevational view thereof;
(56) References Cited FIG. 5 is a left side elevational thereof;
FIG. 7 is a top plan view thereof.
D223,024 S * 2, 1972 Thomas ....................... D12/159
D335,851 S * 5/1993 Lofy ............................ D12/159 1 Claim, 3 Drawing Sheets
USDC IN/ND case 2:19-cv-00207 document 1-1 filed 05/31/19 page 7 of 23

U.S. Patent Aug. 16, 2016 Sheet 1 of 3 US D763,741 S


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U.S. Patent Aug. 16, 2016 Sheet 2 of 3 US D763,741 S

FIG. 4

FIG. 5
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U.S. Patent Aug. 16, 2016 Sheet 3 of 3 US D763,741 S


USDC IN/ND case 2:19-cv-00207 document 1-1 filed 05/31/19 page 10 of 23

Exhibit B
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USOOD763741S

(12) United States Design Patent (10) Patent No.: US D763,741 S


Chen (45) Date of Patent: . Aug. 16, 2016

(54) SET OF VEHICLE CONTROL ARMS R s : '92. yester . . . . . . . . . . . . . . . . . . . . . . R.32


Oll . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D496,887 S * 10/2004 Carlson ........................ D12/159
(71) Applicant: Jacky Chen, City of Industry, CA (US) D543,492 S * 5/2007 Lyew ........................... D12/159
D545,246 S * 6/2007 Kroeker ....................... D12/159
(72) Inventor: Jacky Chen, City of Industry, CA (US) D716,193 S * 10/2014 Hsu .............................. D12/159
D727,218 S * 4/2015 Hsu .............................. D12/159
ck
(**) Term: 14 Years * cited by examiner
(21) Appl. No. 29/517,113 Primary Examiner — Michael A Pratt
1-1. (74) Attorney, Agent, or Firm — Che-Yang Chen; Law
(22) Filed: Feb. 10, 2015 Offices of Scott Warmuth
(51) LOC (10) Cl. ................................................ 12-16
(52) U.S. Cl. (57) CLAIM
USPC ......................................................... D12/159 The ornamental design for a set of vehicle control arms, as
(58) Field of Classification Search shown and described.
USPC ......................................................... D22/159 DESCRIPTION
CPC ............. B60G 7/001; B60G 2200/142: B60G
2200/1424; B60G 2200/154: B60G 2204/418: FIG. 1 is a perspective view of the set of vehicle control arms
B60G 2206/122; B60G 2206/16; B60G 3/20; showing my new design;
B60G 7/008 FIG. 2 is a front elevational view thereof
See application file for complete search history. FIG. 3 is a rear elevational view thereof;
FIG. 4 is a right side elevational view thereof;
(56) References Cited FIG. 5 is a left side elevational thereof;
FIG. 7 is a top plan view thereof.
D223,024 S * 2, 1972 Thomas ....................... D12/159
D335,851 S * 5/1993 Lofy ............................ D12/159 1 Claim, 3 Drawing Sheets
USDC IN/ND case 2:19-cv-00207 document 1-2 filed 05/31/19 page 2 of 4

U.S. Patent Aug. 16, 2016 Sheet 1 of 3 US D763,741 S


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U.S. Patent Aug. 16, 2016 Sheet 2 of 3 US D763,741 S

FIG. 4

FIG. 5
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U.S. Patent Aug. 16, 2016 Sheet 3 of 3 US D763,741 S


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AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT


for the
Northern District
__________ District of
of Indiana
__________

DNA MOTOR, INC., A CALIFORNIA CORPORATION )


)
)
)
Plaintiff(s) )
)
v. Civil Action No. 2:19-CV-207
)
EMOTOR INDUSTRIES INTERNATIONAL )
SHANGHAI CO., LTC., ALSO KNOW AS E-MOTOR
)
USA, INC. AND/OR EMUSA AUTOMOTIVE
)
)
Defendant(s) )

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address) XIAOYONG CHEN


1536 PARK WEST CIRCLE
MUNSTER, IN 46321

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you
are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.
P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of
the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,
whose name and address are:
Patrick J. Olmstead, Jr.
PATRICK OLMSTEAD LAW LLC
P.O, Box 1067
Greenwood, IN 46142
Telephone/Fax: 317-884-8524
E-mail: polmstead@patrickolmsteadlaw.com

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint.
You also must file your answer or motion with the court.

CLERK OF COURT

Date: 05/31/2019
Signature of Clerk or Deputy Clerk
USDC IN/ND case 2:19-cv-00207 document 1-4 filed 05/31/19 page 2 of 2
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No. 2:19-CV-207

PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any) Xiaoyong Chen
was received by me on (date) 05/31/2019 .

’ I personally served the summons on the individual at (place)


on (date) ; or

’ I left the summons at the individual’s residence or usual place of abode with (name)
, a person of suitable age and discretion who resides there,
on (date) , and mailed a copy to the individual’s last known address; or

’ I served the summons on (name of individual) , who is


designated by law to accept service of process on behalf of (name of organization)
on (date) ; or

’ I returned the summons unexecuted because ; or

’ Other (specify):
.

My fees are $ for travel and $ for services, for a total of $ 0.00 .

I declare under penalty of perjury that this information is true.

Date:
Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc:


USDC IN/ND case 2:19-cv-00207 document 1-5 filed 05/31/19 page 1 of 2
AO 440 (Rev. 06/12) Summons in a Civil Action

UNITED STATES DISTRICT COURT


for the
Northern District
__________ District of
of Indiana
__________

DNA MOTOR, INC., A CALIFORNIA CORPORATION )


)
)
)
Plaintiff(s) )
)
v. Civil Action No. 2:19-CV-207
)
EMOTOR INDUSTRIES INTERNATIONAL )
SHANGHAI CO., LTC., ALSO KNOW AS E-MOTOR
)
USA, INC. AND/OR EMUSA AUTOMOTIVE
)
)
Defendant(s) )

SUMMONS IN A CIVIL ACTION

To: (Defendant’s name and address) E-MOTOR USA, INC


202 W. RIDGE ROAD
GRIFFITH, IN 46319

A lawsuit has been filed against you.

Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you
are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.
P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of
the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,
whose name and address are:
Patrick J. Olmstead, Jr.
PATRICK OLMSTEAD LAW LLC
P.O, Box 1067
Greenwood, IN 46142
Telephone/Fax: 317-884-8524
E-mail: polmstead@patrickolmsteadlaw.com

If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint.
You also must file your answer or motion with the court.

CLERK OF COURT

Date: 05/31/2019
Signature of Clerk or Deputy Clerk
USDC IN/ND case 2:19-cv-00207 document 1-5 filed 05/31/19 page 2 of 2
AO 440 (Rev. 06/12) Summons in a Civil Action (Page 2)

Civil Action No. 2:19-CV-207

PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))

This summons for (name of individual and title, if any) E-MOTOR USA, INC.
was received by me on (date) 05/31/2019 .

’ I personally served the summons on the individual at (place)


on (date) ; or

’ I left the summons at the individual’s residence or usual place of abode with (name)
, a person of suitable age and discretion who resides there,
on (date) , and mailed a copy to the individual’s last known address; or

’ I served the summons on (name of individual) , who is


designated by law to accept service of process on behalf of (name of organization)
on (date) ; or

’ I returned the summons unexecuted because ; or

’ Other (specify):
.

My fees are $ for travel and $ for services, for a total of $ 0.00 .

I declare under penalty of perjury that this information is true.

Date:
Server’s signature

Printed name and title

Server’s address

Additional information regarding attempted service, etc: