Fill and Sign the In United States District Court for the Southern District of Form

IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI , PLAINTIFFVS. CAUSE NO. , DEFENDANTS COMPLAINT COMES Plaintiff, , and file this his/her Complaint against and and would state in support thereof, the following: 1. Defendant, is a corporation qualified to do business in Mississippi and may be served with process at by Certified Mail. Defendant, is a resident of . 2. On or about , Defendant, issued a life insurance policy to the Deceased, , in the amount of $ All payments were paid when due and the policy was in force and effect on the date of the death of . 3. departed this life on the day of , 20 and Plaintiff is the Administrator/Administratrix of his/her estate. A copy of the life insurance policy is attached hereto as Exhibit " " and Letters of Administration are attached hereto as Exhibit " ". 4. The policy named the Beneficiary thereof, . The Plaintiff would show unto the Court that and were divorced prior to his/her death and that by said divorce, Defendant, , waived all right to entitlement to the proceeds of said life insurance policy. In the alternative, he/she should be estopped to claim said proceeds. 5. Defendant, has refused to pay contending that the beneficiary designation by remains in effect despite the divorce. Plaintiff requests that the Court enter an Order awarding unto the Estate of , the full sum of Dollars ($ ) plus interest and attorneys fees.WHEREFORE, PREMISES CONSIDERED, Plaintiff prays that the Court will enter an Order awarding the Estate of , Dollars ($ ) plus interest from the date of death, from Defendant, , and further declare that the Defendant, , has no entitlement to said proceeds. RESPECTFULLY SUBMITTED, this the day of , 20 . ___________________________________ , AS ADMINISTRATRIX OFTHE ESTATE OF BY: _____________________________________ ATTORNEY FOR PLAINTIFF IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI PLAINTIFFVS. CAUSE NO. DEFENDANTS SUMMONS THE STATE OF MISSISSIPPICOUNTY OF TO: NOTICE TO DEFENDANT THE COMPLAINT WHICH IS ATTACHED TO THIS SUMMONS IS IMPORTANT AND YOU MUST TAKE IMMEDIATE ACTION TO PROTECT YOUR RIGHTS.You are required to mail or hand deliver a copy of a written response to the Complaint to , the attorney for the Plaintiff, whose post office address is , and whose street address is .YOUR RESPONSE MUST BE MAILED OR DELIVERED WITHIN THIRTY (30) DAYS FROM THE DATE OF DELIVERY OF THIS SUMMONS AND COMPLAINT OR A JUDGMENT BY DEFAULT WILL BE ENTERED AGAINST YOU FOR THE MONEY OR OTHER THINGS DEMANDED IN THE COMPLAINT.You must also file the original of your response with the Clerk of this Court within a reasonable time afterward.ISSUED under my hand and seal of said Court, this day of , 20 . _____________________________ , CHANCERY CLERK(Seal) OF COUNTY , Mississippi By: Deputy Clerk IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI PLAINTIFFVS. CAUSE NO. DEFENDANTS SUMMONS THE STATE OF MISSISSIPPICOUNTY OF TO: NOTICE TO DEFENDANT THE COMPLAINT WHICH IS ATTACHED TO THIS SUMMONS IS IMPORTANT AND YOU MUST TAKE IMMEDIATE ACTION TO PROTECT YOUR RIGHTS.You are required to mail or hand deliver a copy of a written response to the Complaint to , the attorney for the Plaintiff, whose post office address is and whose street address is .YOUR RESPONSE MUST BE MAILED OR DELIVERED WITHIN THIRTY (30) DAYS FROM THE DATE OF DELIVERY OF THIS SUMMONS AND COMPLAINT OR A JUDGMENT BY DEFAULT WILL BE ENTERED AGAINST YOU FOR THE MONEY OR OTHER THINGS DEMANDED IN THE COMPLAINT.You must also file the original of your response with the Clerk of this Court within a reasonable time afterward.ISSUED under my hand and seal of said Court, this day of , 20 . ______________________________ , CHANCERY CLERK(Seal) OF COUNTY , Mississippi By: ______________________________ Deputy Clerk