Case 2:17-cv-04263-JVS-JCG Document 2 Filed 06/08/17 Page 1 of 3 Page ID #:104
`UNITED STATES DISTRICT COURT, CENTRAL DISTRICT OF CALIFORNIA
`CIVIL COVER SHEET
`I. (a) PLAINTIFFS ( Check box if you are representing yourself
`DEFENDANTS (
`)
`
`Check box if you are representing yourself
`
`)
`
`(b) County of Residence of First Listed Plaintiff
`(EXCEPT IN U.S. PLAINTIFF CASES)
`(c) Attorneys (Firm Name, Address and Telephone Number) If you are
`representing yourself, provide the same information.
`
`County of Residence of First Listed Defendant
`(IN U.S. PLAINTIFF CASES ONLY)
`Attorneys (Firm Name, Address and Telephone Number) If you are
`representing yourself, provide the same information.
`
`4
`
`5 6
`
`DEF
`
`4
`
`5
`
`6
`
`III. CITIZENSHIP OF PRINCIPAL PARTIES-For Diversity Cases Only
`(Place an X in one box for plaintiff and one for defendant)
`PTF
`DEF
`PTF
`Incorporated or Principal Place
`of Business in this State
`Incorporated and Principal Place
`of Business in Another State
`Foreign Nation
`
`1
`
`2 3
`
`1
`
`2
`
`3
`
`Citizen of This State
`
`Citizen of Another State
`
`Citizen or Subject of a
`Foreign Country
`
`II. BASIS OF JURISDICTION (Place an X in one box only.)
`
`1. U.S. Government
`Plaintiff
`
`3. Federal Question (U.S.
`Government Not a Party)
`
`2. U.S. Government
`Defendant
`
`4. Diversity (Indicate Citizenship
`of Parties in Item III)
`
`IV. ORIGIN (Place an X in one box only.)
` 1. Original
`2. Removed from
`3. Remanded from
` State Court
` Appellate Court
` Proceeding
`
`4. Reinstated or
` Reopened
`
` 5. Transferred from Another
` District (Specify)
`
`6. Multidistrict
` Litigation -
` Transfer
`
`8. Multidistrict
` Litigation -
` Direct File
`
`V. REQUESTED IN COMPLAINT: JURY DEMAND:
`CLASS ACTION under F.R.Cv.P. 23:
`$
`MONEY DEMANDED IN COMPLAINT:
`No
`Yes
`VI. CAUSE OF ACTION (Cite the U.S. Civil Statute under which you are filing and write a brief statement of cause. Do not cite jurisdictional statutes unless diversity.)
`
`Yes
`
`No
`
`(Check "Yes" only if demanded in complaint.)
`
`VII. NATURE OF SUIT (Place an X in one box only).
`OTHER STATUTES
`CONTRACT
`REAL PROPERTY CONT.
`110 Insurance
`240 Torts to Land
`245 Tort Product
`Liability
`290 All Other Real
`Property
`TORTS
`PERSONAL INJURY
`310 Airplane
`315 Airplane
`Product Liability
`320 Assault, Libel &
`Slander
`330 Fed. Employers'
`Liability
`340 Marine
`345 Marine Product
`Liability
`350 Motor Vehicle
`355 Motor Vehicle
`Product Liability
`360 Other Personal
`Injury
`362 Personal Injury-
`Med Malpratice
`365 Personal Injury-
`Product Liability
`367 Health Care/
`Pharmaceutical
`Personal Injury
`Product Liability
`368 Asbestos
`Personal Injury
`Product Liability
`
`120 Marine
`
`130 Miller Act
`140 Negotiable
`Instrument
`150 Recovery of
`Overpayment &
`Enforcement of
`Judgment
`151 Medicare Act
`
`152 Recovery of
`Defaulted Student
`Loan (Excl. Vet.)
`
`153 Recovery of
`Overpayment of
`Vet. Benefits
`160 Stockholders'
` Suits
`
`190 Other
`Contract
` 195 Contract
`Product Liability
`196 Franchise
`REAL PROPERTY
`210 Land
`Condemnation
`220 Foreclosure
`230 Rent Lease &
`Ejectment
`
`375 False Claims Act
`
`376 Qui Tam
`(31 USC 3729(a))
`400 State
`Reapportionment
`410 Antitrust
`430 Banks and Banking
`450 Commerce/ICC
`Rates/Etc.
`460 Deportation
`470 Racketeer Influ-
`enced & Corrupt Org.
`480 Consumer Credit
`490 Cable/Sat TV
`850 Securities/Com-
`modities/Exchange
`890 Other Statutory
`Actions
`891 Agricultural Acts
`893 Environmental
`Matters
`895 Freedom of Info.
`Act
`896 Arbitration
`
`899 Admin. Procedures
`Act/Review of Appeal of
`Agency Decision
`950 Constitutionality of
`State Statutes
`
`PROPERTY RIGHTS
`820 Copyrights
`830 Patent
`840 Trademark
`SOCIAL SECURITY
`861 HIA (1395ff)
`862 Black Lung (923)
`863 DIWC/DIWW (405 (g))
`864 SSID Title XVI
`865 RSI (405 (g))
`
`FEDERAL TAX SUITS
`870 Taxes (U.S. Plaintiff or
`Defendant)
`871 IRS-Third Party 26 USC
`7609
`
`IMMIGRATION
`462 Naturalization
`Application
`
`465 Other
`Immigration Actions
`TORTS
`PERSONAL PROPERTY
`370 Other Fraud
`371 Truth in Lending
`380 Other Personal
`Property Damage
`385 Property Damage
`Product Liability
`BANKRUPTCY
`422 Appeal 28
`USC 158
`423 Withdrawal 28
`USC 157
`CIVIL RIGHTS
`440 Other Civil Rights
`441 Voting
`442 Employment
`443 Housing/
`Accommodations
`445 American with
`Disabilities-
`Employment
`446 American with
`Disabilities-Other
`448 Education
`
`PRISONER PETITIONS
`Habeas Corpus:
`463 Alien Detainee
`510 Motions to Vacate
`Sentence
`530 General
`535 Death Penalty
` Other:
`540 Mandamus/Other
`550 Civil Rights
`555 Prison Condition
`560 Civil Detainee
`Conditions of
`Confinement
`FORFEITURE/PENALTY
`625 Drug Related
`Seizure of Property 21
`USC 881
`690 Other
`LABOR
`710 Fair Labor Standards
`Act
`720 Labor/Mgmt.
`Relations
`740 Railway Labor Act
`751 Family and Medical
`Leave Act
`790 Other Labor
`Litigation
`791 Employee Ret. Inc.
`Security Act
`
`FOR OFFICE USE ONLY:
`CV-71 (07/16)
`
`Case Number:
`
`CIVIL COVER SHEET
`
`Page 1 of 3
`
`

`

`Case 2:17-cv-04263-JVS-JCG Document 2 Filed 06/08/17 Page 2 of 3 Page ID #:105
`UNITED STATES DISTRICT COURT, CENTRAL DISTRICT OF CALIFORNIA
`CIVIL COVER SHEET
`
`STATE CASE WAS PENDING IN THE COUNTY OF:
`
`INITIAL DIVISION IN CACD IS:
`
`VIII. VENUE: Your answers to the questions below will determine the division of the Court to which this case will be initially assigned. This initial assignment is subject
`to change, in accordance with the Court's General Orders, upon review by the Court of your Complaint or Notice of Removal.
`QUESTION A: Was this case removed
`from state court?
`Yes
`
`
`If "no, " skip to Question B. If "yes," check the
`box to the right that applies, enter the
`corresponding division in response to
`Question E, below, and continue from there.
`
`No
`
`Los Angeles, Ventura, Santa Barbara, or San Luis Obispo
`
`Orange
`
`Riverside or San Bernardino
`
`Western
`
`Southern
`
`Eastern
`
`QUESTION B: Is the United States, or
`one of its agencies or employees, a
`PLAINTIFF in this action?
`
`
`
`
`If "no, " skip to Question C. If "yes," answer
`Question B.1, at right.
`
`Yes
`
`No
`
`QUESTION C: Is the United States, or
`one of its agencies or employees, a
`DEFENDANT in this action?
`
`
`
`
`If "no, " skip to Question D. If "yes," answer
`Question C.1, at right.
`
`Yes
`
`No
`
`B.1. Do 50% or more of the defendants who reside in
`the district reside in Orange Co.?
`
`
`check one of the boxes to the right
`
`YES. Your case will initially be assigned to the Southern Division.
`Enter "Southern" in response to Question E, below, and continue
`from there.
`
`B.2. Do 50% or more of the defendants who reside in
`the district reside in Riverside and/or San Bernardino
`Counties? (Consider the two counties together.)
`
`
`check one of the boxes to the right
`
`NO. Continue to Question B.2.
`
`YES. Your case will initially be assigned to the Eastern Division.
`Enter "Eastern" in response to Question E, below, and continue
`from there.
`
`NO. Your case will initially be assigned to the Western Division.
`Enter "Western" in response to Question E, below, and continue
`from there.
`
`C.1. Do 50% or more of the plaintiffs who reside in the
`district reside in Orange Co.?
`
`
`check one of the boxes to the right
`
`YES. Your case will initially be assigned to the Southern Division.
`Enter "Southern" in response to Question E, below, and continue
`from there.
`
`C.2. Do 50% or more of the plaintiffs who reside in the
`district reside in Riverside and/or San Bernardino
`Counties? (Consider the two counties together.)
`
`
`check one of the boxes to the right
`
`NO. Continue to Question C.2.
`
`YES. Your case will initially be assigned to the Eastern Division.
`Enter "Eastern" in response to Question E, below, and continue
`from there.
`
`NO. Your case will initially be assigned to the Western Division.
`Enter "Western" in response to Question E, below, and continue
`from there.
`
`QUESTION D: Location of plaintiffs and defendants?
`
`Indicate the location(s) in which 50% or more of plaintiffs who reside in this district
`reside. (Check up to two boxes, or leave blank if none of these choices apply.)
`Indicate the location(s) in which 50% or more of defendants who reside in this
`district reside. (Check up to two boxes, or leave blank if none of these choices
`apply.)
`
`A.
`
`Orange County
`
`B.
`Riverside or San
`Bernardino County
`
`C.
`Los Angeles, Ventura,
`Santa Barbara, or San
`Luis Obispo County
`
`D.1. Is there at least one answer in Column A?
`Yes
`No
`
`If "yes," your case will initially be assigned to the
`SOUTHERN DIVISION.
`
`D.2. Is there at least one answer in Column B?
`Yes
`No
`
`If "yes," your case will initially be assigned to the
`EASTERN DIVISION.
`
` Enter "Southern" in response to Question E, below, and continue from there.
`
` Enter "Eastern" in response to Question E, below.
`
` If "no," go to question D2 to the right.
`
` If "no," your case will be assigned to the WESTERN DIVISION.
`
`QUESTION E: Initial Division?
`
`Enter the initial division determined by Question A, B, C, or D above:
`
`QUESTION F: Northern Counties?
`
`Enter "Western" in response to Question E, below.
`
`INITIAL DIVISION IN CACD
`
`Do 50% or more of plaintiffs or defendants in this district reside in Ventura, Santa Barbara, or San Luis Obispo counties?
`
`Yes
`
`No
`
`CV-71 (07/16)
`
`CIVIL COVER SHEET
`
`Page 2 of 3
`
`

`

`Case 2:17-cv-04263-JVS-JCG Document 2 Filed 06/08/17 Page 3 of 3 Page ID #:106
`UNITED STATES DISTRICT COURT, CENTRAL DISTRICT OF CALIFORNIA
`CIVIL COVER SHEET
`
`IX(a). IDENTICAL CASES: Has this action been previously filed in this court?
`
`
`
`If yes, list case number(s):
`
`IX(b). RELATED CASES: Is this case related (as defined below) to any civil or criminal case(s) previously filed in this court?
`
`NO
`
`YES
`
`NO
`
`YES
`
`If yes, list case number(s):
`
`Civil cases are related when they (check all that apply):
`
`A. Arise from the same or a closely related transaction, happening, or event;
`
`B. Call for determination of the same or substantially related or similar questions of law and fact; or
`
`C. For other reasons would entail substantial duplication of labor if heard by different judges.
`
`Note: That cases may involve the same patent, trademark, or copyright is not, in itself, sufficient to deem cases related.
`
`A civil forfeiture case and a criminal case are related when they (check all that apply):
`
`A. Arise from the same or a closely related transaction, happening, or event;
`
`B. Call for determination of the same or substantially related or similar questions of law and fact; or
`
`C. Involve one or more defendants from the criminal case in common and would entail substantial duplication of
`labor if heard by different judges.
`
`X. SIGNATURE OF ATTORNEY
`(OR SELF-REPRESENTED LITIGANT):
`
`DATE:
`
`Notice to Counsel/Parties: The submission of this Civil Cover Sheet is required by Local Rule 3-1. This Form CV-71 and the information contained herein
`neither replaces nor supplements the filing and service of pleadings or other papers as required by law, except as provided by local rules of court. For
`more detailed instructions, see separate instruction sheet (CV-071A).
`
`Key to Statistical codes relating to Social Security Cases:
`
`Nature of Suit Code Abbreviation
`
`861
`
`862
`
`863
`
`863
`
`864
`
`865
`
`
`
`
`
`
`
`
`
`
`
`
`
` HIA
`
` BL
`
` DIWC
`
` DIWW
`
` SSID
`
` RSI
`
`
`
`
`
`
`
`
`
`
`
`
`
`Substantive Statement of Cause of Action
`
`All claims for health insurance benefits (Medicare) under Title 18, Part A, of the Social Security Act, as amended. Also,
`include claims by hospitals, skilled nursing facilities, etc., for certification as providers of services under the program.
`(42 U.S.C. 1935FF(b))
`
`All claims for "Black Lung" benefits under Title 4, Part B, of the Federal Coal Mine Health and Safety Act of 1969. (30 U.S.C.
`923)
`
`All claims filed by insured workers for disability insurance benefits under Title 2 of the Social Security Act, as amended; plus
`all claims filed for child's insurance benefits based on disability. (42 U.S.C. 405 (g))
`
`All claims filed for widows or widowers insurance benefits based on disability under Title 2 of the Social Security Act, as
`amended. (42 U.S.C. 405 (g))
`
`All claims for supplemental security income payments based upon disability filed under Title 16 of the Social Security Act, as
`amended.
`
`All claims for retirement (old age) and survivors benefits under Title 2 of the Social Security Act, as amended.
`(42 U.S.C. 405 (g))
`
`CV-71 (07/16)
`
`CIVIL COVER SHEET
`
`Page 3 of 3
`
`