Civil Cover Sheet

---

U.S. District Court
[Insert District Name] District of [State Name]

1. (a) PLAINTIFF(S):
John Doe
1234 Maple Street
City, State 12345
Phone: (555) 123-4567

(b) DEFENDANT(S):
Acme Corporation
5678 Oak Avenue
City, State 67890
Phone: (555) 987-6543

---

2. BASIS OF JURISDICTION (Place an “X” in one box only):

• 1. U.S. Government Plaintiff

• 2. U.S. Government Defendant

• 3. Federal Question (U.S. plaintiff or defendant)

• 4. Diversity (Complete item 6)

---

3. CITIZENSHIP OF PRINCIPAL PARTIES (Diversity cases only):

Plaintiff:

• Individual

• Corporation (if more than one box is checked, state citizenship of each)

Defendant:

• Corporation (Acme Corporation is incorporated in Delaware)

• Individual

---

4. NATURE OF SUIT (Place an “X” in one box only):

• 110 - Contract

• 120 - Marine

• 130 - Miller Act

• 140 - Negotiable Instrument

• 150 - Recovery of Overpayment & Enforcement of Judgment

• 160 - Stockholders' Suits

• 190 - Other Contract

• 220 - Foreclosure

• 230 - Rent, Lease & Ejectment

• 240 - Torts to Land

• 250 - Tort Product Liability

• 310 - Airplane

• 315 - Airplane Product Liability

• 320 - Assault, Libel & Slander

• 330 - Federal Employers' Liability

• 340 - Marine

• 350 - Motor Vehicle

• 360 - Other Personal Injury

• 370 - Other Fraud

• 380 - Other Personal Property Damage

• 410 - Antitrust

• 420 - Copyright

• 430 - Patent

• 440 - Other Intellectual Property

• 450 - Labor/Management Relations

• 460 - Immigration

• 470 - Racketeer Influenced & Corrupt Organizations

• 480 - Consumer Credit

• 490 - Cable/Satellite TV

• 510 - Motions to Vacate Sentence

• 530 - Habeas Corpus

• 540 - Mandamus & Other

• 550 - Civil Rights

• 555 - Prison Condition

• 560 - Bankruptcy

• 610 - Agriculture

• 620 - Other Food & Drug

• 625 - Drug Related Seizure of Property

• 630 - Liquor Laws

• 640 - RICO

• 650 - Airline Regs

• 660 - Occupational Safety & Health

• 690 - Other Statutory Actions

---

5. CAUSE OF ACTION:

Violation of the Federal Fair Labor Standards Act, 29 U.S.C. § 201 et seq.
Plaintiff alleges that Defendant failed to pay overtime wages as required by federal law.

---

6. REQUESTED IN COMPLAINT:

• CLASS ACTION

• YES

• NO

---

7. RELATED CASE(S) (See instructions):

• YES

• NO

If yes, please complete related case form.

Case Number: 2050-CV-00123

---

8. DEMAND FOR TRIAL BY JURY:

• YES

• NO

---

9. SIGNATURE OF ATTORNEY (OR PLAINTIFF):

Date: December 9, 2050

Signature:

[Your Name]

Attorney for Plaintiff, John Doe

Law Firm: [Your Company Name]

[Your Company Address]

[Your Email]

---

Fax Cover Sheet Templates @ Template.net