Pro Se 6 (Rev.

12/16) Complaint for a Civil Case Alleging that the Defendant Owes the Plaintiff a Sum of Money

UNITED STATES DISTRICT COURT

for the
__________
__________ District
District of
of __________
__________

__________ Division
__________ Division

Case No.
) (to be filled in by the Clerk’s Office)
)
Plaintiff(s) )
(Write the full name of each plaintiff who is filing this complaint. )
If the names of all the plaintiffs cannot fit in the space above,
Jury Trial: (check one) ’ Yes ’ No
)
please write “see attached” in the space and attach an additional
page with the full list of names.) )
-v- )
)
)
)
)
)
Defendant(s)
(Write the full name of each defendant who is being sued. If the
)
names of all the defendants cannot fit in the space above, please )
write “see attached” in the space and attach an additional page )
with the full list of names.)

COMPLAINT FOR A CIVIL CASE ALLEGING THAT THE

DEFENDANT OWES PLAINTIFF A SUM OF MONEY
(28 U.S.C. § 1332; Diversity of Citizenship)

I. The Parties to This Complaint

A. The Plaintiff(s)

Provide the information below for each plaintiff named in the complaint. Attach additional pages if
needed.
Name
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address

B. The Defendant(s)

Provide the information below for each defendant named in the complaint, whether the defendant is an
individual, a government agency, an organization, or a corporation. For an individual defendant,
include the person's job or title (if known). Attach additional pages if needed.

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Pro Se 6 (Rev. 12/16) Complaint for a Civil Case Alleging that the Defendant Owes the Plaintiff a Sum of Money

Defendant No. 1
Name
Job or Title (if known)
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)

Defendant No. 2
Name
Job or Title (if known)
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)

Defendant No. 3
Name
Job or Title (if known)
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)

Defendant No. 4
Name
Job or Title (if known)
Street Address
City and County
State and Zip Code
Telephone Number
E-mail Address (if known)

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Pro Se 6 (Rev. 12/16) Complaint for a Civil Case Alleging that the Defendant Owes the Plaintiff a Sum of Money

II. Basis for Jurisdiction

Federal courts are courts of limited jurisdiction (limited power). Under 28 U.S.C. § 1332, federal courts may
hear cases in which a citizen of one State sues a citizen of another State or nation and the amount at stake is
more than $75,000. In that kind of case, called a diversity of citizenship case, no defendant may be a citizen of
the same State as any plaintiff. Explain how these jurisdictional requirements have been met.

A. The Plaintiff(s)

1. If the plaintiff is an individual

The plaintiff, (name) , is a citizen of the
State of (name) .

2. If the plaintiff is a corporation

The plaintiff, (name) , is incorporated
under the laws of the State of (name) ,
and has its principal place of business in the State of (name)
.

(If more than one plaintiff is named in the complaint, attach an additional page providing the
same information for each additional plaintiff.)

B. The Defendant(s)

1. If the defendant is an individual

The defendant, (name) , is a citizen of
the State of (name) . Or is a citizen of
(foreign nation) .

2. If the defendant is a corporation

The defendant, (name) , is incorporated under
the laws of the State of (name) , and has its
principal place of business in the State of (name) .
Or is incorporated under the laws of (foreign nation) ,
and has its principal place of business in (name) .

(If more than one defendant is named in the complaint, attach an additional page providing the
same information for each additional defendant.)

C. The Amount in Controversy

The amount in controversy–the amount the plaintiff claims the defendant owes or the amount at
stake–is more than $75,000, not counting interest and costs of court, because (explain):

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Pro Se 6 (Rev. 12/16) Complaint for a Civil Case Alleging that the Defendant Owes the Plaintiff a Sum of Money

III. Statement of Claim

Write a short and plain statement of the claim. Do not make legal arguments. State as briefly as possible the
facts showing that each plaintiff is entitled to the damages or other relief sought. State how each defendant was
involved and what each defendant did that caused the plaintiff harm or violated the plaintiff's rights, including
the dates and places of that involvement or conduct. If more than one claim is asserted, number each claim and
write a short and plain statement of each claim in a separate paragraph. Attach additional pages if needed.

The defendant, (name) , owes the plaintiff (specify the

amount) $ , because (use one or more of the following, as appropriate):

A. On a Promissory Note
On (date) , the defendant signed and delivered a note promising to pay the plaintiff
on (date) the sum of (specify the amount) $ with interest at the rate
of (specify the amount) percent. The defendant has not paid the amount due and owes
(state the amount of unpaid principal and interest) $ . A copy of the note is attached as an
exhibit or is summarized below. (Attach the note or summarize what the document says.)

B. On an Account Between the Parties

The defendant owes the plaintiff (specify the amount) $ . This debt arises from an
account between the parties, based on (state the basis, such as an agreement between a credit–card company and a
credit–card holder)

The plaintiff sent the defendant a statement of the account listing the transactions over a certain period
and showing the bills sent, the payments received or credits approved, and the balance due. The
defendant owes (specify the amount) $ . Copies of the bills or account statements are
attached as exhibits or summarized below. (Attach the statements or summarize what they say.)

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Pro Se 6 (Rev. 12/16) Complaint for a Civil Case Alleging that the Defendant Owes the Plaintiff a Sum of Money

C. For Goods Sold and Delivered

The defendant owes the plaintiff (specify the amount) $ , for goods sold and delivered
by the plaintiff to the defendant from (date) to (date) .

D. For Money Loaned

The defendant owes the plaintiff (specify the amount) $ , for money the plaintiff loaned
the defendant on (date) .

E. For Money Paid by Mistake

The defendant owes the plaintiff (specify the amount) $ for money paid by mistake to
the defendant on (date) , when the defendant received the payment from (specify who
paid and describe the circumstances of the payment)

F. For Money Had and Received

The defendant was paid money (specify the amount) $ on (date) by
(identify who paid and describe the circumstances of the payment)

It is unjust for the defendant not to pay the plaintiff the money received because (explain the reason, such as
that the money was intended to be paid to the plaintiff, or was paid by coercion, duress, or fraud, or was an overpayment or a

deposit to be returned)

IV. Relief

State briefly and precisely what damages or other relief the plaintiff asks the court to order. Do not make legal
arguments. Include any basis for claiming that the wrongs alleged are continuing at the present time. Include
the amounts of any actual damages claimed for the acts alleged and the basis for these amounts. Include any
punitive or exemplary damages claimed, the amounts, and the reasons you claim you are entitled to actual or
punitive money damages.

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Pro Se 6 (Rev. 12/16) Complaint for a Civil Case Alleging that the Defendant Owes the Plaintiff a Sum of Money

V. Certification and Closing

Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my knowledge, information,
and belief that this complaint: (1) is not being presented for an improper purpose, such as to harass, cause
unnecessary delay, or needlessly increase the cost of litigation; (2) is supported by existing law or by a
nonfrivolous argument for extending, modifying, or reversing existing law; (3) the factual contentions have
evidentiary support or, if specifically so identified, will likely have evidentiary support after a reasonable
opportunity for further investigation or discovery; and (4) the complaint otherwise complies with the
requirements of Rule 11.

A. For Parties Without an Attorney

I agree to provide the Clerk’s Office with any changes to my address where case–related papers may be
served. I understand that my failure to keep a current address on file with the Clerk's Office may result
in the dismissal of my case.

Date of signing:

Signature of Plaintiff
Printed Name of Plaintiff

B. For Attorneys

Date of signing:

Signature of Attorney
Printed Name of Attorney
Bar Number
Name of Law Firm
Street Address
State and Zip Code
Telephone Number
E-mail Address

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