(2) The names of the people you are suing as the Defendants.
(3) Fill in your county and one defendant's county.
(4) Under "Plaintiff's Attorney" put "Pro Se," your name, prisoner number if applicable, and address.
(5) Leave "Defendant's Attorney" blank.
(6) Under "Basis of Jurisdiction," check the appropriate block. (see INSTRUCTIONS)
(7) Under "Citizenship" (residence) fill in the appropriate information, if Basis of Jurisdiction is Diversity. Otherwise, leave blank.
(8) Under "Nature of Suit" check the appropriate box.
(9) Under "Origin," check box 1: "Original Proceeding."
(10) Under "Cause of Action," put the statute you cited in your complaint's jurisdictional statement.
(11) Under "Requested in Complaint," write in the amount of money you are suing for, and check the appropriate box after "jury demand."
(12) List all related cases, by Court and Docket Number, that you have filed regarding the claims in this action.
(13) Date the form, and sign your name, followed by "Pro Se" on the last line.
