Pro Se Complaint Form

In the United States Court of Federal Claims Plaintiff(s), v. THE UNITED STATES, Defendant. ) ) ) ) ) ) ) ) ) ) ) ) Case No. Judge COMPLAINT Your complaint must be clearly handwritten or typewritten, and you must sign and declare under penalty of perjury that the facts are correct. If you need additional space, you may use another blank page. If you intend to proceed without the prepayment of filing fees (in forma pauperis (IFP)), pursuant to 28 U.S.C. 247 1915, you must file along with your complaint an application to proceed IFP. 1. JURISDICTION. State the grounds for filing this case in the United States Court of Federal Claims. The United States Court of Federal Claims has limited jurisdiction (see e.g., 28 U.S.C. 247247 1491-1509). American LegalNet, Inc. www.FormsWorkFlow.com 2. PARTIES Plaintiff,, resides at (Street Address) , (City, State, ZIP Code) (Telephone Number) If more than one plaintiff, provide the same information for each plaintiff below. RELATED CASES. Is this case directly related to any pending or previously filed cases in the United States Court of Federal Claims? Yes No If yes, please list the case(s) below, including case number(s): 3. STATEMENT OF THE CLAIM. State as briefly as possible the facts of your case. Describe how the United States is involved. You must state exactly what the United States did, or failed to do, that has caused you to initiate this legal action. Be as specific as possible and use additional paper as necessary. American LegalNet, Inc. www.FormsWorkFlow.com 4. RELIEF. Briefly state exactly what you want the court to do for you. I declare under penalty of perjury that the foregoing is true and correct. Signed this day of,. (day) (month) (year) Signature of Plaintiff(s) American LegalNet, Inc. www.FormsWorkFlow.com