Fill and Sign the Pro Se Form

- 1 - IN THE UNITED STATES DISTRICT COURT FOR THE __________________ DISTRICT OF ______________________ Pro Se [Non-Prisoner] Complaint Form - 2 - Enter the full name of the plaintiff in this action ____________________________________ ________________________________________________________________________v. Enter below the full name of defendant(s) in this action. If possible, please list only one defendant per line. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________) ) )Civil Action No. _____________________ )(to be assigned by Clerk))))))))))))))))))))))))))) If allowed by statute, do you wish to have a trial by jury? Yes ________ No _________ I. PREVIOUS LAWSUITS A. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action? - 3 - Yes __________ No _________ B. If your answer to A is Yes, describe the lawsuit in the space below. If there is more than one lawsuit, describe the additional lawsuits on another piece of paper using the same outline. 1. Parties to this previous lawsuit: Plaintiff: ____________________________________________________________ Defendant(s): ________________________________________________________ 2. Court: ______________________________________________________________ (If federal court, name the district; if state court, name the county) 3. Docket Number: ______________________________________________________ 4. Name(s) of Judge(s) to whom case was assigned: ____________________________ 5. Status of Case: _______________________________________________________ (For example, was the case dismissed? Settled? Appealed? Still Pending?) 6. Date lawsuit was filed: _________________________________________________ 7. Date of disposition (if concluded): ________________________________________ C. Do you have any other lawsuits pending in the federal court in South Carolina? Yes _______ No _______ II. PARTIES In Item A below, place your name and address in the space provided. Do the same for additional plaintiffs, if any. A. Name of Plaintiff:________________________________________________________ Address: _______________________________________________________________ In Item B below, place the full name of the defendant; and his, her, or its address, in the space provided. Use Item C for additional defendants, if any. B. Name of Defendant: ______________________________________________________ - 4 - Address: _______________________________________________________________ C. Additional Defendants (provide the same information for each defendant as listed in Item B above): ___________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ III. STATEMENT OF CLAIM State here, as briefly as possible, the facts of your case. Describe how each defendant is involved. Include also the name(s) of other persons involved, dates, and places. Do not give any legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate paragraph. Use as much space as you need. Attach extra sheets if necessary. __________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - 5 - __________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ III. STATEMENT OF CLAIM - continued. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - 6 - __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ IV. RELIEF. State briefly and exactly what you want this court to do for you. __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ - 7 - Signed this __________________ day of _______, 20_____.____________________________________ Signature of Plaintiff