Fill and Sign the Declaratory 481378309 Form

IN THE UNITED STATES DISTRICT COURT FOR THE ____________ DISTRICT OF ___________ ___________________ DIVISION NAME OF PLAINTIFF) ) V. )NAME OF DEFENDANTS)NO. )Natural Mother and Guardian))Individually)) COMPLAINT FOR RECOVERY ANDFOR DECLARATORY JUDGMENT JURY TRIAL REQUESTED COMES NOW Plaintiff, ______________, and files this its Complaint for Recovery and for Declaratory Judgment, pursuant to Title 28 U.S.C., Section 2201 and Rule 57 of the Federal Rules of Civil Procedure, and in support thereof would show unto the Court the following: PARTIES 1.______________ is an insurance company organized and existing under the laws of the State of __________, whose principal office is in __________, qualified to do and doing business within the State of __________, whose mailing address is Post Office Box ______________, __________, __________ _____(zip code).2.Defendant, ______________, is an adult resident citizen of __________, who resides in this court's judicial district.3.Defendant, ______________, as mother and natural guardian of ______________, and ______________, individually, reside in this court's judicial district. JURISDICTION AND VENUE 4. This Court has jurisdiction over this action pursuant to 28 U.S.C. Section 1332 in that the parties are citizens of different states, and the amount in controversy exceeds $75,000.00 exclusive of interest and costs, in that Defendant ______________ claims damages in excess of $75,000.00. 5.Venue is proper in the United States District Court for the __________ District of __________, pursuant to 28 U.S.C. Section 1391(A) in that the claim arose in this judicial district and the defendants reside in this district. NATURE OF ACTION 6. This is an action for recovery of monies paid and for declaratory judgment pursuant to Title 28, U.S.C. Section 2201 and Rule 57, Federal Rules of Civil Procedure, for the purpose of determining a question of actual controversy between the parties as hereinafter more fully appears. GENERAL ALLEGATIONS 7.On or about __________ __, _____, ______________ and ______________ were involved in an automobile accident. As a result of the accident ______________ received certain injuries and has incurred medical bills amounting to approximately $_______.____.8.At the time of the accident ______________ was insured under a policy of insurance with ______________ bearing policy no. ______________.9.______________ is making claims against ______________ under the uninsured motorist provisions of her policy alleging that ______________ was guilty of negligence proximately causing the accident in question and further alleging that ______________ was an underinsured motorist. If ______________ is found to be liable to ______________ for damages, it is liable based solely on the uninsured motorist provisions of the policy in question.10. ______________ has a subrogation claim against ______________ for any amount ______________ has paid or is ultimately required to pay to or on behalf of ______________ under the policy in question as a result of the subject accident and as provided in __________ Section __________ (______).11. ____________ has already paid $_______.______ to ____________ and is thus subrogated to the interest of ____________ to the extent of the $______.____ paid by ______________ against any monies to be recovered from ____________.12. ____________ has also paid for certain medical and property damage and is subrogated to the interest of ____________ to the extent of any payments for medical and property damage.13. ______________ is also making claims for damages against ______________ that exceed the minimum jurisdictional limits of this court all of which ______________ has a subrogation right against ______________ for any amount ______________ is ultimately required to pay to or on behalf of ______________ under the policy in issue as a result of the subject accident, as provided in _________ Section ________ (________).14.An actual controversy exists within the jurisdiction of this court between __________, __________ and ____________ as to the liability of the parties in the subject accident, the amount of damages owed among the parties, and the subrogation interest of ____________. WHEREFORE, PREMISES CONSIDERED, the plaintiff, ____________, prays for a judgment against _____________ for all sums paid to or on behalf of ____________, for a judgment for all sums that ______________ may ultimately have to pay to or on behalf of ______________ and for this court to determine the responsibility of the parties in question.Dated this the ____ day of __________, 2001. Respectfully submitted, ________________________________