Professional Documents
Culture Documents
1. $350 Filing Fee - unless you are GRANTED the right to proceed
without prepayment of fees. If you are DENIED the right to
proceed without prepayment of fees, you will have 30 days to pay
the filing fee or your case will be converted to a miscellaneous
case and automatically dismissed by the court.
4. Submit 3 summons for each defendant - one for the court, one
to serve with the complaint and a copy to return to the court
after service has been effected.
(b) County of Residence of First Listed Plaintiff County of Residence of First Listed Defendant
(EXCEPT IN U.S. PLAINTIFF CASES) (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 (Place an “X” in One Box Only) III. CITIZENSHIP OF PRINCIPAL PARTIES(Place an “X” in One Box for Plaintiff
(For Diversity Cases Only) and One Box for Defendant)
’ 1 U.S. Government ’ 3 Federal Question PTF DEF PTF DEF
Plaintiff (U.S. Government Not a Party) Citizen of This State ’ 1 ’ 1 Incorporated or Principal Place ’ 4 ’ 4
of Business In This State
’ 2 U.S. Government ’ 4 Diversity Citizen of Another State ’ 2 ’ 2 Incorporated and Principal Place ’ 5 ’ 5
Defendant of Business In Another State
(Indicate Citizenship of Parties in Item III)
Citizen or Subject of a ’ 3 ’ 3 Foreign Nation ’ 6 ’ 6
Foreign Country
IV. NATURE OF SUIT (Place an “X” in One Box Only)
CONTRACT TORTS FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES
’ 110 Insurance PERSONAL INJURY PERSONAL INJURY ’ 610 Agriculture ’ 422 Appeal 28 USC 158 ’ 400 State Reapportionment
’ 120 Marine ’ 310 Airplane ’ 362 Personal Injury - ’ 620 Other Food & Drug ’ 423 Withdrawal ’ 410 Antitrust
’ 130 Miller Act ’ 315 Airplane Product Med. Malpractice ’ 625 Drug Related Seizure 28 USC 157 ’ 430 Banks and Banking
’ 140 Negotiable Instrument Liability ’ 365 Personal Injury - of Property 21 USC 881 ’ 450 Commerce
’ 150 Recovery of Overpayment ’ 320 Assault, Libel & Product Liability ’ 630 Liquor Laws PROPERTY RIGHTS ’ 460 Deportation
& Enforcement of Judgment Slander ’ 368 Asbestos Personal ’ 640 R.R. & Truck ’ 820 Copyrights ’ 470 Racketeer Influenced and
’ 151 Medicare Act ’ 330 Federal Employers’ Injury Product ’ 650 Airline Regs. ’ 830 Patent Corrupt Organizations
’ 152 Recovery of Defaulted Liability Liability ’ 660 Occupational ’ 840 Trademark ’ 480 Consumer Credit
Student Loans ’ 340 Marine PERSONAL PROPERTY Safety/Health ’ 490 Cable/Sat TV
(Excl. Veterans) ’ 345 Marine Product ’ 370 Other Fraud ’ 690 Other ’ 810 Selective Service
’ 153 Recovery of Overpayment Liability ’ 371 Truth in Lending LABOR SOCIAL SECURITY ’ 850 Securities/Commodities/
of Veteran’s Benefits ’ 350 Motor Vehicle ’ 380 Other Personal ’ 710 Fair Labor Standards ’ 861 HIA (1395ff) Exchange
’ 160 Stockholders’ Suits ’ 355 Motor Vehicle Property Damage Act ’ 862 Black Lung (923) ’ 875 Customer Challenge
’ 190 Other Contract Product Liability ’ 385 Property Damage ’ 720 Labor/Mgmt. Relations ’ 863 DIWC/DIWW (405(g)) 12 USC 3410
’ 195 Contract Product Liability ’ 360 Other Personal Product Liability ’ 730 Labor/Mgmt.Reporting ’ 864 SSID Title XVI ’ 890 Other Statutory Actions
’ 196 Franchise Injury & Disclosure Act ’ 865 RSI (405(g)) ’ 891 Agricultural Acts
REAL PROPERTY CIVIL RIGHTS PRISONER PETITIONS ’ 740 Railway Labor Act FEDERAL TAX SUITS ’ 892 Economic Stabilization Act
’ 210 Land Condemnation ’ 441 Voting ’ 510 Motions to Vacate ’ 790 Other Labor Litigation ’ 870 Taxes (U.S. Plaintiff ’ 893 Environmental Matters
’ 220 Foreclosure ’ 442 Employment Sentence ’ 791 Empl. Ret. Inc. or Defendant) ’ 894 Energy Allocation Act
’ 230 Rent Lease & Ejectment ’ 443 Housing/ Habeas Corpus: Security Act ’ 871 IRS—Third Party ’ 895 Freedom of Information
’ 240 Torts to Land Accommodations ’ 530 General 26 USC 7609 Act
’ 245 Tort Product Liability ’ 444 Welfare ’ 535 Death Penalty IMMIGRATION ’ 900Appeal of Fee Determination
’ 290 All Other Real Property ’ 445 Amer. w/Disabilities - ’ 540 Mandamus & Other ’ 462 Naturalization Application Under Equal Access
Employment ’ 550 Civil Rights ’ 463 Habeas Corpus - to Justice
’ 446 Amer. w/Disabilities - ’ 555 Prison Condition Alien Detainee ’ 950 Constitutionality of
Other ’ 465 Other Immigration State Statutes
’ 440 Other Civil Rights Actions
VII. REQUESTED IN ’ CHECK IF THIS IS A CLASS ACTION DEMAND $ CHECK YES only if demanded in complaint:
COMPLAINT: UNDER F.R.C.P. 23 JURY DEMAND: ’ Yes ’ No
VIII. RELATED CASE(S)
(See instructions):
IF ANY JUDGE DOCKET NUMBER
IF YOU CANNOT AFFORD TO PAY THE FILING FEE you may be allowed to
have the filing fee waived if you fill out the following form and
send it to the court with the complaint, cover sheet and
completed summons forms:
AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
)
Plaintiff/Petitioner )
v. ) Civil Action No.
)
Defendant/Respondent )
I am a plaintiff or petitioner in this case and declare Complete all questions in this application and then sign it.
that I am unable to pay the costs of these proceedings Do not leave any blanks: if the answer to a question is “0,”
and that I am entitled to the relief requested. I declare “none,” or “not applicable (N/A),” write that response. If
under penalty of perjury that the information below is you need more space to answer a question or to explain your
true and understand that a false statement may result in answer, attach a separate sheet of paper identified with your
a dismissal of my claims. name, your case's docket number, and the question number.
Signed: 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 amounts, that is, amounts before any deductions
for taxes or otherwise.
Income source Average monthly income Income amount expected
amount during the past 12 next month
months
You Spouse You Spouse
Employment
$ $ $ $
Self-employment
$ $ $ $
Income from real property (such as rental income)
$ $ $ $
Interest and dividends
$ $ $ $
Gifts
$ $ $ $
Alimony
$ $ $ $
Child support
$ $ $ $
Page 2 of 5
AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or
other deductions.)
3. List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is before
taxes or other deductions.)
$ $
$ $
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.
Page 3 of 5
AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary
household furnishings.
Assets owned by you or your spouse
Home (Value) $
Other real estate (Value)
$
Model:
Registration #:
Model:
Registration #:
6. State every person, business, or organization owing you or your spouse money, and the amount owed.
Person owing you or your spouse Amount owed to you Amount owed to your spouse
money
$ $
$ $
$ $
7. State the persons who rely on you or your spouse for support.
Name (or, if under 18, initials only) Relationship Age
Page 4 of 5
AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
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, semiannually, or annually to show the
monthly rate.
You Your spouse
Food $ $
Clothing $ $
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: $ $
Other: $ $
AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
Other (specify): $ $
$ 0.00 $ 0.00
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.
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 costs of these proceedings.
_____________ DIVISION
______________________________)
______________________________)
______________________________)
(Enter above the full name
of the Plaintiff[s] in this
action).
Case No. ________________
vs. (To be assigned
by the 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).
COMPLAINT
_________________________________________________________________
_________________________________________________________________
2. Defendant(s)name(s):_________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
1
Location of principal office(s) of the named defendant(s):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
§ 20003-5(g).
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
2
5. Plaintiff is:
following:
____________________________________________________________
____________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3
8. The alleged discrimination occurred on or about _____________
________________________________________________________________.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
________________________________________________________________.
_________________________________________________________________
____________________________.
4
12. I seek the following relief:
______________ ________________________________________
Date Signature of Plaintiff
________________________________________
________________________________________
________________________________________
________________________________________
Address and Phone Number of Plaintiff
5
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF NORTH CAROLINA
Case No.
)
)
Plaintiff(s), )
)
vs )
)
)
Defendant(s). )
Pursuant to Fed.R.Civ.P. 7.1 and Local Civil Rule 7.3, or Fed.R.Crim.P. 12.4 and Local Criminal
Rule 12.3,
YES NO
YES NO
If yes, identify all parent corporation, including grandparent and great-grandparent corporations:
3. Is 10% or more of the stock of a party owned by a publicly held corporation or other
publicly held entity?
YES NO
YES NO
YES NO
If yes, identify all members of the association, their parent corporations, and any publicly held
companies that own 10% or more of a member’s stock:
6. If case arises out of a bankruptcy proceeding, identify any trustee and the members of any
creditors’s committee:
Signature: _____________________________
Date: _____________________________
)
)
Plaintiff
)
v. ) Civil Action No.
)
)
Defendant
)
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:
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:
Signature of Clerk or Deputy Clerk
AO 440 (Rev. 12/09) Summons in a Civil Action (Page 2)
PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))
’ 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
’ Other (specify):
.
My fees are $ for travel and $ for services, for a total of $ 0.00 .
Date:
Server’s signature
Server’s address
)
)
Plaintiff
)
v. ) Civil Action No.
)
)
Defendant
)
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:
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:
Signature of Clerk or Deputy Clerk
AO 440 (Rev. 12/09) Summons in a Civil Action (Page 2)
PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))
’ 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
’ Other (specify):
.
My fees are $ for travel and $ for services, for a total of $ 0.00 .
Date:
Server’s signature
Server’s address
)
)
Plaintiff
)
v. ) Civil Action No.
)
)
Defendant
)
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:
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:
Signature of Clerk or Deputy Clerk
AO 440 (Rev. 12/09) Summons in a Civil Action (Page 2)
PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))
’ 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
’ Other (specify):
.
My fees are $ for travel and $ for services, for a total of $ 0.00 .
Date:
Server’s signature
Server’s address