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):
3. CITIZENSHIP OF PRINCIPAL PARTIES (Diversity cases only):
Plaintiff:
Defendant:
4. NATURE OF SUIT (Place an “X” in one box only):
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:
7. RELATED CASE(S) (See instructions):
If yes, please complete related case form.
Case Number: 2050-CV-00123
8. DEMAND FOR TRIAL BY JURY:
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]
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