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UNITED STATES DISTRICT COURT, CENTRAL DISTRICT OF CALIFORNIA (US Courts)

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UNITED STATES DISTRICT COURT, CENTRAL DISTRICT OF CALIFORNIA
CIVIL COVER SHEET
I. (a) PLAINTIFFS (
Check box if you are representing yourself
DEFENDANTS (
(c)
Attorneys (Firm Name, Address and Telephone Number) If you are
representing yourself, provide the same information.
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)
III. CITIZENSHIP OF PRINCIPAL PARTIES-For Diversity Cases Only
(Place an X in one box for plaintiff and one for defendant)
Citizen of This State
Citizen or Subject of a
Foreign Country
Citizen of Another State
PTF DEF
1 1
3
2
3
Incorporated or Principal Place
of Business in this State
Incorporated and Principal Place
of Business in Another State
Foreign Nation
DEFPTF
4 4
5 5
66
2
IV. ORIGIN (Place an X in one box only.)
1. Original
Proceeding
2. Removed from
State Court
3. Remanded from
Appellate Court
4. Reinstated or
Reopened
6. Multidistrict
Litigation -
Transfer
V. REQUESTED IN COMPLAINT: JURY DEMAND: Yes No
(Check "Yes" only if demanded in complaint.)
CLASS ACTION under F.R.Cv.P. 23:
No MONEY DEMANDED IN COMPLAINT: 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 Do not cite jurisdictional statutes unless diversity.)
VII. NATURE OF SUIT (Place an X in one box only).
CONTRACT
TORTS
PERSONAL INJURY
PRISONER PETITIONS
LABOR
REAL PROPERTY
IMMIGRATION
BANKRUPTCY
CIVIL RIGHTS
FORFEITURE/PENALTY
PROPERTY RIGHTS
SOCIAL SECURITY
FEDERAL TAX SUITS
375 False Claims Act
400 State
Reapportionment
410 Antitrust
430 Banks and Banking
490 Cable/Sat TV
480 Consumer Credit
460 Deportation
896 Arbitration
895 Freedom of Info.
Act
893 Environmental
Matters
891 Agricultural Acts
899 Admin. Procedures
Act/Review of Appeal of
Agency Decision
450 Commerce/ICC
Rates/Etc.
470 Racketeer Influ-
enced & Corrupt Org.
850 Securities/Com-
modities/Exchange
890 Other Statutory
Actions
110 Insurance
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
210 Land
Condemnation
220 Foreclosure
230 Rent Lease &
Ejectment
REAL PROPERTY CONT.
240 Torts to Land
245 Tort Product
Liability
290 All Other Real
Property
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
950 Constitutionality of
State Statutes
462 Naturalization
Application
465 Other
Immigration Actions
370 Other Fraud
371 Truth in Lending
380 Other Personal
Property Damage
385 Property Damage
Product Liability
422 Appeal 28
USC 158
423 Withdrawal 28
USC 157
441 Voting
442 Employment
443 Housing/
Accommodations
445 American with
Disabilities-
Employment
446 American with
Disabilities-Other
440 Other Civil Rights
448 Education
510 Motions to Vacate
Sentence
530 General
535 Death Penalty
540 Mandamus/Other
550 Civil Rights
555 Prison Condition
560 Civil Detainee
Conditions of
Confinement
625 Drug Related
Seizure of Property 21
USC 881
690 Other
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
820 Copyrights
830 Patent
835 Patent - Abbreviated
New Drug Application
861 HIA (1395ff)
862 Black Lung (923)
863 DIWC/DIWW (405 (g))
864 SSID Title XVI
865 RSI (405 (g))
870 Taxes (U.S. Plaintiff or
Defendant)
871 IRS-Third Party 26 USC
7609
FOR OFFICE USE ONLY:
Habeas Corpus:
463 Alien Detainee
Other:
)
5. Transferred from Another
District (Specify)
OTHER STATUTES
TORTS
PERSONAL PROPERTY
Check box if you are representing yourself
Attorneys (Firm Name, Address and Telephone Number) If you are
representing yourself, provide the same information.
)
$
Page 1 of 3CV-71 (05/17) CIVIL COVER SHEET
(b) County of Residence of First Listed Plaintiff County of Residence of First Listed Defendant
(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY)
Case Number:
376 Qui Tam
(31 USC 3729(a))
8. Multidistrict
Litigation -
Direct File
840 Trademark
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?
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.
NoYes
STATE CASE WAS PENDING IN THE COUNTY OF: INITIAL DIVISION IN CACD IS:
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.
NoYes
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.
Page 2 of 3CV-71 (05/17) CIVIL COVER SHEET
UNITED STATES DISTRICT COURT, CENTRAL DISTRICT OF CALIFORNIA
CIVIL COVER SHEET
YES. Your case will initially be assigned to the Southern Division.
Enter "Southern" in response to Question E, below, and continue
from there.
A.
Orange County
B.
Riverside or San
Bernardino County
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.)
D.1. Is there at least one answer in Column A? D.2. Is there at least one answer in Column B?
If "yes," your case will initially be assigned to the
SOUTHERN DIVISION.
Enter "Southern" in response to Question E, below, and continue from there.
If "no," go to question D2 to the right.
QUESTION E: Initial Division?
Enter the initial division determined by Question A, B, C, or D above:
INITIAL DIVISION IN CACD
QUESTION D: Location of plaintiffs and defendants?
If "yes," your case will initially be assigned to the
EASTERN DIVISION.
Enter "Eastern" in response to Question E, below.
If "no," your case will be assigned to the WESTERN DIVISION.
Enter "Western" in response to Question E, below.
Yes No Yes No
NO. Your case will initially be assigned to the Western Division.
Enter "Western" in response to Question E, below, and continue
from there.
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
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
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
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
YES. Your case will initially be assigned to the Southern Division.
Enter "Southern" in response to Question E, below, and continue
from there.
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.
C.
Los Angeles, Ventura,
Santa Barbara, or San
Luis Obispo County
QUESTION F: Northern Counties?
Do 50% or more of plaintiffs or defendants in this district reside in Ventura, Santa Barbara, or San Luis Obispo counties?
Yes No
IX(a). IDENTICAL CASES: Has this action been previously filed in this court?
NO YES
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
Civil cases are related when they (check all that apply):
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:
861 HIA
862 BL
863 DIWW
863 DIWC
864 SSID
865 RSI
Nature of Suit Code Abbreviation 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))
If yes, list case number(s):
If yes, list case number(s):
DATE:
X. SIGNATURE OF ATTORNEY
(OR SELF-REPRESENTED LITIGANT):
CV-71 (05/17) Page 3 of 3CIVIL COVER SHEET
UNITED STATES DISTRICT COURT, CENTRAL DISTRICT OF CALIFORNIA
CIVIL COVER SHEET
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. 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
A civil forfeiture case and a criminal case are related when they (check all that apply):
C. Involve one or more defendants from the criminal case in common and would entail substantial duplication of
labor if heard by different judges.
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Completed 10 August 2020

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