Pro Se Unhoused Camping Lawsuit Template With Application For Restraining Order

JS-CAND 44 (Rev.
10/2020)
CIVIL COVER SHEET
The JS-CAND 44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law,
except as provided by local rules of court. This form, approved in its original form by the Judicial Conference of the United States in September 1974, is required for the Clerk of
Court to initiate the civil docket sheet. (SEE INSTRUCTIONS ON NEXT PAGE OF THIS FORM.)
I. (a) PLAINTIFFS DEFENDANTS
(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)
NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF
THE TRACT OF LAND INVOLVED.
(c) Attorneys (Firm Name, Address, and Telephone Number) Attorneys (If Known)
II. BASIS OF JURISDICTION (Place an “X” in One Box Only) III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an “X” in One Box for Plaintiff
(For Diversity Cases Only) and One Box for Defendant)
PTF DEF PTF DEF
1 U.S. Government Plaintiff 3 Federal Question Citizen of This State 1 1 Incorporated or Principal Place 4 4
(U.S. Government Not a Party)
of Business In This State
Citizen of Another State 2 2 Incorporated and Principal Place 5 5
2 U.S. Government Defendant 4 Diversity of Business In Another State
(Indicate Citizenship of Parties in Item III)
Citizen or Subject of a 3 3 Foreign Nation 6 6
Foreign Country
IV. NATURE OF SUIT (Place an “X” in One Box Only)

CONTRACT TORTS FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES
110 Insurance PERSONAL INJURY PERSONAL INJURY 625 Drug Related Seizure of 422 Appeal 28 USC § 158 375 False Claims Act
120 Marine Property 21 USC § 881 423 Withdrawal 28 USC 376 Qui Tam (31 USC
310 Airplane 365 Personal Injury – Product
130 Miller Act Liability 690 Other § 157 § 3729(a))
315 Airplane Product Liability
140 Negotiable Instrument 367 Health Care/ LABOR PROPERTY RIGHTS 400 State Reapportionment
320 Assault, Libel & Slander
150 Recovery of Pharmaceutical Personal 410 Antitrust
330 Federal Employers’ 710 Fair Labor Standards Act 820 Copyrights
Overpayment Of Injury Product Liability 430 Banks and Banking
Liability 720 Labor/Management 830 Patent
Veteran’s Benefits 368 Asbestos Personal Injury 450 Commerce
340 Marine Relations 835 Patent─Abbreviated New
151 Medicare Act Product Liability
345 Marine Product Liability 740 Railway Labor Act Drug Application 460 Deportation
152 Recovery of Defaulted PERSONAL PROPERTY 470 Racketeer Influenced &
350 Motor Vehicle 751 Family and Medical 840 Trademark
Student Loans (Excludes 370 Other Fraud Corrupt Organizations
355 Motor Vehicle Product Leave Act 880 Defend Trade Secrets
Veterans) 371 Truth in Lending
Liability 790 Other Labor Litigation Act of 2016 480 Consumer Credit
153 Recovery of 380 Other Personal Property
360 Other Personal Injury 791 Employee Retirement 485 Telephone Consumer
Overpayment Damage
SOCIAL SECURITY
Income Security Act Protection Act
of Veteran’s Benefits 362 Personal Injury -Medical 861 HIA (1395ff)
Malpractice 385 Property Damage Product 490 Cable/Sat TV
160 Stockholders’ Suits Liability IMMIGRATION 862 Black Lung (923) 850 Securities/Commodities/
190 Other Contract 462 Naturalization 863 DIWC/DIWW (405(g)) Exchange
CIVIL RIGHTS PRISONER PETITIONS
195 Contract Product Liability Application 864 SSID Title XVI
440 Other Civil Rights 890 Other Statutory Actions
HABEAS CORPUS 465 Other Immigration
196 Franchise 865 RSI (405(g)) 891 Agricultural Acts
441 Voting 463 Alien Detainee Actions
REAL PROPERTY 442 Employment FEDERAL TAX SUITS 893 Environmental Matters
510 Motions to Vacate
210 Land Condemnation 443 Housing/ Sentence 870 Taxes (U.S. Plaintiff or 895 Freedom of Information
Accommodations Defendant) Act
220 Foreclosure 530 General
445 Amer. w/Disabilities– 871 IRS–Third Party 26 USC 896 Arbitration
230 Rent Lease & Ejectment 535 Death Penalty
Employment § 7609 899 Administrative Procedure
240 Torts to Land OTHER
446 Amer. w/Disabilities–Other Act/Review or Appeal of
245 Tort Product Liability 540 Mandamus & Other Agency Decision
290 All Other Real Property 448 Education
550 Civil Rights 950 Constitutionality of State
555 Prison Condition Statutes
560 Civil Detainee–
Conditions of
Confinement
V. ORIGIN (Place an “X” in One Box Only)

1 Original 2 Removed from 3 Remanded from 4 Reinstated or 5 Transferred from 6 Multidistrict 8 Multidistrict
Proceeding State Court Appellate Court Reopened Another District (specify) Litigation–Transfer Litigation–Direct File
VI. CAUSE OF Cite the U.S. Civil Statute under which you are filing (Do not cite jurisdictional statutes unless diversity):
ACTION
Brief description of cause:
VII. REQUESTED IN CHECK IF THIS IS A CLASS ACTION DEMAND $ CHECK YES only if demanded in complaint:
COMPLAINT: UNDER RULE 23, Fed. R. Civ. P. JURY DEMAND: Yes No
VIII. RELATED CASE(S), JUDGE DOCKET NUMBER

IF ANY (See instructions):
IX. DIVISIONAL ASSIGNMENT (Civil Local Rule 3-2)
(Place an “X” in One Box Only) SAN FRANCISCO/OAKLAND SAN JOSE EUREKA-MCKINLEYVILLE
DATE SIGNATURE OF ATTORNEY OF RECORD

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JS-CAND 44 (rev. 10/2020)
INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS-CAND 44
Authority For Civil Cover Sheet. The JS-CAND 44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and
service of pleading or other papers as required by law, except as provided by local rules of court. This form, approved in its original form by the Judicial
Conference of the United States in September 1974, is required for the Clerk of Court to initiate the civil docket sheet. Consequently, a civil cover sheet is
submitted to the Clerk of Court for each civil complaint filed. The attorney filing a case should complete the form as follows:
I. a) Plaintiffs-Defendants. Enter names (last, first, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency, use
only the full name or standard abbreviations. If the plaintiff or defendant is an official within a government agency, identify first the agency and
then the official, giving both name and title.
b) County of Residence. For each civil case filed, except U.S. plaintiff cases, enter the name of the county where the first listed plaintiff resides at the
time of filing. In U.S. plaintiff cases, enter the name of the county in which the first listed defendant resides at the time of filing. (NOTE: In land
condemnation cases, the county of residence of the “defendant” is the location of the tract of land involved.)
c) Attorneys. Enter the firm name, address, telephone number, and attorney of record. If there are several attorneys, list them on an attachment, noting
in this section “(see attachment).”
II. Jurisdiction. The basis of jurisdiction is set forth under Federal Rule of Civil Procedure 8(a), which requires that jurisdictions be shown in
pleadings. Place an “X” in one of the boxes. If there is more than one basis of jurisdiction, precedence is given in the order shown below.
(1) United States plaintiff. Jurisdiction based on 28 USC §§ 1345 and 1348. Suits by agencies and officers of the United States are included here.
(2) United States defendant. When the plaintiff is suing the United States, its officers or agencies, place an “X” in this box.
(3) Federal question. This refers to suits under 28 USC § 1331, where jurisdiction arises under the Constitution of the United States, an amendment
to the Constitution, an act of Congress or a treaty of the United States. In cases where the U.S. is a party, the U.S. plaintiff or defendant code
takes precedence, and box 1 or 2 should be marked.
(4) Diversity of citizenship. This refers to suits under 28 USC § 1332, where parties are citizens of different states. When Box 4 is checked, the
citizenship of the different parties must be checked. (See Section III below; NOTE: federal question actions take precedence over diversity
cases.)
III. Residence (citizenship) of Principal Parties. This section of the JS-CAND 44 is to be completed if diversity of citizenship was indicated above.
Mark this section for each principal party.
IV. Nature of Suit. Place an “X” in the appropriate box. If the nature of suit cannot be determined, be sure the cause of action, in Section VI below, is
sufficient to enable the deputy clerk or the statistical clerk(s) in the Administrative Office to determine the nature of suit. If the cause fits more than
one nature of suit, select the most definitive.
V. Origin. Place an “X” in one of the six boxes.
(1) Original Proceedings. Cases originating in the United States district courts.
(2) Removed from State Court. Proceedings initiated in state courts may be removed to the district courts under Title 28 USC § 1441. When the
petition for removal is granted, check this box.
(3) Remanded from Appellate Court. Check this box for cases remanded to the district court for further action. Use the date of remand as the filing
date.
(4) Reinstated or Reopened. Check this box for cases reinstated or reopened in the district court. Use the reopening date as the filing date.
(5) Transferred from Another District. For cases transferred under Title 28 USC § 1404(a). Do not use this for within district transfers or
multidistrict litigation transfers.
(6) Multidistrict Litigation Transfer. Check this box when a multidistrict case is transferred into the district under authority of Title 28 USC
§ 1407. When this box is checked, do not check (5) above.
(8) Multidistrict Litigation Direct File. Check this box when a multidistrict litigation case is filed in the same district as the Master MDL docket.
Please note that there is no Origin Code 7. Origin Code 7 was used for historical records and is no longer relevant due to changes in statute.
VI. Cause of Action. Report the civil statute directly related to the cause of action and give a brief description of the cause. Do not cite jurisdictional
statutes unless diversity. Example: U.S. Civil Statute: 47 USC § 553. Brief Description: Unauthorized reception of cable service.
VII. Requested in Complaint. Class Action. Place an “X” in this box if you are filing a class action under Federal Rule of Civil Procedure 23.
Demand. In this space enter the actual dollar amount being demanded or indicate other demand, such as a preliminary injunction.
Jury Demand. Check the appropriate box to indicate whether or not a jury is being demanded.
VIII. Related Cases. This section of the JS-CAND 44 is used to identify related pending cases, if any. If there are related pending cases, insert the docket
numbers and the corresponding judge names for such cases.
IX. Divisional Assignment. If the Nature of Suit is under Property Rights or Prisoner Petitions or the matter is a Securities Class Action, leave this
section blank. For all other cases, identify the divisional venue according to Civil Local Rule 3-2: “the county in which a substantial part of the
events or omissions which give rise to the claim occurred or in which a substantial part of the property that is the subject of the action is situated.”
Date and Attorney Signature. Date and sign the civil cover sheet.
Clear Form
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8 UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA
9
)
10 )
)
11 Plaintiff, ) CASE NO.
)
12 vs. ) APPLICATION TO PROCEED
) IN FORMA PAUPERIS
13 ) (Non-prisoner cases only)
)
14 Defendant. )
)
15
16 I, , declare, under penalty of perjury that I am the plaintiff
17 in the above entitled case and that the information I offer throughout this application is true and
18 correct. I offer this application in support of my request to proceed without being required to
19 prepay the full amount of fees, costs or give security. I state that because of my poverty I am
20 unable to pay the costs of this action or give security, and that I believe that I am entitled to relief.
21 In support of this application, I provide the following information:
22 1. Are you presently employed? Yes No
23 If your answer is "yes," state both your gross and net salary or wages per month, and give the
24 name and address of your employer:
25 Gross: Net:
26 Employer:
27
28 If the answer is "no," state the date of last employment and the amount of the gross and net salary
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1 and wages per month which you received.
2
3
4
5 2. Have you received, within the past twelve (12) months, any money from any of the
6 following sources:
7 a. Business, Profession or Yes No
8 self employment?
9 b. Income from stocks, bonds, Yes No
10 or royalties?
11 c. Rent payments? Yes No
12 d. Pensions, annuities, or Yes No
13 life insurance payments?
14 e. Federal or State welfare payments, Yes No
15 Social Security or other govern-
16 ment source?
17 If the answer is "yes" to any of the above, describe each source of money and state the amount
18 received from each.
19
20
21 3. Are you married? Yes No
22 Spouse's Full Name:
23 Spouse's Place of Employment:
24 Spouse's Monthly Salary, Wages or Income:
25 Gross $ Net $
26 4. a. List amount you contribute to your spouse's support:$
27 b. List the persons other than your spouse who are dependent upon you for support
28 and indicate how much you contribute toward their support. (NOTE: For minor
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1 children, list only their initials and ages. DO NOT INCLUDE THEIR NAMES.)
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3
4 5. Do you own or are you buying a home? Yes No
5 Estimated Market Value: $ Amount of Mortgage: $
6 6. Do you own an automobile? Yes No
7 Make Year Model
8 Is it financed? Yes No If so, Total due: $
9 Monthly Payment: $
10 7. Do you have a bank account? Yes No (Do not include account numbers.)
11 Name(s) and address(es) of bank:
12
13 Present balance(s): $
14 Do you own any cash? Yes No Amount: $
15 Do you have any other assets? (If "yes," provide a description of each asset and its estimated
16 market value.) Yes No
17
18 8. What are your monthly expenses?
19 Rent: $ Utilities:
20 Food: $ Clothing:
21 Charge Accounts:
22 Name of Account Monthly Payment Total Owed on This Account
23 $ $
24 $ $
25 $ $
26 9. Do you have any other debts? (List current obligations, indicating amounts and to whom
27 they are payable. Do not include account numbers.)
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2 10. Does the complaint which you are seeking to file raise claims that have been presented in
3 other lawsuits? Yes No
4 Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in
5 which they were filed.
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8 I declare under the penalty of perjury that the foregoing is true and correct and understand that a
9 false statement herein may result in the dismissal of my claims.
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12 DATE SIGNATURE OF APPLICANT
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Instructions: Writing and Filing a Civil Complaint
This Complaint template was prepared by the Justice & Diversity Center, a nonprofit organization,
and is not an official court form. It can be used by persons who are not incarcerated to file civil
lawsuits in the Northern District Court of California. This template provides guidance only. Using
this template does not guarantee any result in your case.
HOW TO GET LEGAL INFORMATION AND ADVICE
This template provides general guidance. It does not tell you everything you need to know
about filing and serving a Complaint. Before filing your Complaint, make an appointment for free
legal information and advice at one of the Legal Help Centers listed below.
If you will file at the San Francisco or Oakland federal courthouse, do one of the
following:
Call the appointment scheduling line for the Federal Pro Bono Project: 415-782-8982
Sign up in the appointment book at either:

450 Golden Gate Ave., 15th Floor, Room 2796, San Francisco or
1301 Clay Street, 4th Floor, Room 470S, Oakland
Email us at federalprobonoproject@sfbar.org
This email is to schedule appointments - no legal advice is given over email.
If you will file at the San Jose federal courthouse, do one of the following:
Call the appointment scheduling line for the Federal Pro Se Program: 408-297-1480
Monday to Thursday 9:00 am - 12:00 pm, drop in at

The Law Foundation of Silicon Valley, 152 North 3rd St., 3rd Floor, San Jose
Monday to Thursday 1:00 pm - 4:00 pm, drop in at
280 South 1st Street, 2nd Floor, Room 2070, San Jose
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CHECKLIST: DOCUMENTS TO PREPARE
Along with your Complaint, you need to file some official court forms. These forms are also available
at the Legal Help Centers (see page 1), and in a fillable pdf version on the Court’s website at
www.cand.uscourts.gov/Legal-Help-Center-Templates.
 Complaint (see instructions below)
This is a general complaint template. Other types of complaint templates are available at the
Legal Help Centers. Persons who are incarcerated must use a different, official Court form.
 Civil Cover Sheet (information form for the Court’s internal records)
 Summons with Proof of Service (the Clerk must sign and stamp the summons you have
prepared – the completed summons and complaint will be served on the defendant)
 Application to Proceed in Forma Pauperis (request that the court waive the $402 filing fee, if
you cannot afford to pay it)
HOW TO COMPLETE THIS COMPLAINT TEMPLATE
1. Know your deadlines. You have limited time to file your complaint. If you are not sure of
the deadline, contact the Legal Help Centers (see page 1).
2. Review instructions. In the Complaint template, instructions are provided in italics to guide you.
Please read these, as well as Chapter 4 of the Handbook for Pro Se Litigants (see page 4).
3. Provide basic information. Complete pages 1-3 of the Complaint, which provide the Court with
information about you (the plaintiff) and the person or entity you are suing (the defendant), the
law you are suing under, and why this Court is the correct one to decide this case.
4. Write out the facts. Write a short and simple description of what happened that caused you to
file this case. Put each fact into a separate, numbered paragraph, starting with paragraph 6. It is
usually best to write the facts in the order that they happened. Start with the earliest time and
continue until the most recent event. Include where and when each event happened, who was
involved, and what role each defendant played. If you need more pages for your facts, a blank
page for copying is at the end of this packet.
5. Write out the claims. A “claim” explains what kind of legal right you are suing about. You may
have one claim or several. For each claim, write in the law or right that was violated. Then, write
in the name of the defendant who violated that law. Complete your claim by explaining what the
law allows or doesn’t allow, what the defendant did to violate that law, and the ways in which
you were harmed by what the defendant did. Put each statement into a separate, numbered
paragraph. You can briefly repeat facts from your statement of facts. You do not need to include
legal arguments or case law. There two claim templates in this packet. If you have more than two
claims, a blank page for copying is included at the end. If you need help identifying and
understanding your claims, make an appointment at the Legal Help Center (see page 1).
6. You may attach documents to the end of this Complaint as exhibits, but it is not required. If you
do attach an exhibit, explain what it is and how it supports your claim. Attaching a document to
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your Complaint does not necessarily mean that it will be accepted as evidence, and it does not
mean that you should leave anything out of the written portion of your Complaint. An exhibit is
not a substitute for writing out the details of your claims.
7. Identify your demands.
a. Complete the Demand for Relief section on the signature page by writing in what you
would like the Court to do for you.
b. If you would like to request a jury trial at the end of your case, check the boxes for
Demand for Jury Trial on the front and last pages. Not all claims go to a jury trial.
8. Number the pages. Count the number of pages in your final Complaint. In the bottom left
corner of each page, insert the page number and the total.
9. Review and sign your Complaint. Read your Complaint, making sure all blanks are filled in,
and to confirm that all of the statements are true. Each plaintiff must sign the complaint. Add an
additional signature line for any other plaintiffs.
FILING AND SERVING YOUR DOCUMENTS
1. Make two copies. Once you have completely filled out and signed your Complaint, Civil
Case Cover Sheet, Application to Proceed in Forma Pauperis (if needed), and prepared the
Summons for the Clerk, make two copies of each document. On one copy of each document,
write “Chambers” on the top in pen.
2. Deliver or mail the original plus two copies of each form to the Clerk’s Office at the federal
courthouse where you are filing your case. The Clerk will take the original and the copy
marked “Chambers” of each document. The other copy is for you to keep after it is stamped
by the Clerk. If you file by mail, include a self-addressed, stamped envelope so that the Clerk
can send a copy of each document back to you.
3. Serve the Complaint. Be sure that the Complaint, Summons, and the documents you received
from the Clerk are served on each defendant.
a. If you filed an Application to Proceed in Forma Pauperis and it is granted, the Court
will normally order the U.S. Marshalls to serve each defendant.
b. If you did not file an Application to Proceed in Forma Pauperis, you will need to have
someone serve each defendant. For more information on service, contact the Legal
Help Center (see page 1) or read Chapter 8 of the Handbook for Pro Se Litigants.
STAY UP TO DATE
1. Tell the Court if you move. You must file a notice with the Clerk right away if your
mailing address, email, or phone number changes or you may miss important deadlines,
causing you to lose your case.
2. Check your mail. Be sure to check your mail regularly for documents from the Court or
the opposing side.
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3. A list of all of the documents that have been filed, and (usually) the documents themselves
can be viewed online. Review Chapter 7 of the Handbook for Pro Se Litigants (see below),
and contact the Legal Help Center to learn about accessing the documents (see page 1).
TIMELINE: FIRST STEPS IN A CIVIL CASE
This timeline lists the first few things that happen in a civil case. The Legal Help Centers (see page 1)
can provide guidance about these steps, and have many additional templates for documents you may
need to file during this time and throughout your case.
Defendant responds to
Case begins when the Complaint
the Complaint is (usually within 21 days
filed of service)
Complaint, Summons, Attend conference with

and other documents judge to set case
served on defendants schedule
(ASAP) (within 90 days of filing)
UNDERSTANDING THE LAWS AND RULES
The Legal Help Centers (see page 1) are the best resource for people without lawyers. There are other
resources available for understanding the laws and rules of the Court:
1. Handbook for Pro Se Litigants. The Handbook is for people who are representing themselves
and it explains basic court rules and procedures. It was prepared by the Court and is available at
the Clerk’s Office and on the Court’s website at www.cand.uscourts.gov/prosehandbk.
2. Legal Research Guide for Pro Se Litigants. The Guide provides information for people who
are representing themselves about how to do legal research, like finding statutes and decisions in
other cases. It was prepared by the Justice & Diversity Center and is available at the Legal Help
Centers and at http://www.cand.uscourts.gov/Legal-Help-Center-Templates.
3. Federal Rules of Civil Procedure. These Rules explain the procedures from filing through trial
for all civil cases in the federal courts across the country, and are available at
http://www.uscourts.gov/sites/default/files/rules-of-civil-procedure.pdf.
4. Local Rules. The Local Rules are similar to the Federal Rules of Civil Procedure, but they apply
only in this District. They are available at http://www.cand.uscourts.gov/localrules/civil.
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1 Your Name:
2 Address:
3 Phone Number:
4 Fax Number:
5 E-mail Address:
6 Pro Se Plaintiff
7
9 NORTHERN DISTRICT OF CALIFORNIA
10
11 Case Number [leave blank]
12
COMPLAINT
13 Plaintiff,
14 vs.
15
DEMAND FOR JURY TRIAL
16
Yes  No 
17
18
19 Defendant.
20
21 PARTIES
1. Plaintiff. [Write your name, address, and phone number. Add a page for additional
22 plaintiffs.]
23 Name: _____________________________________________________________
24 Address: _____________________________________________________________
25 Telephone: _____________________________________________________________
26
27
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COMPLAINT
PAGE ___ OF ___ [JDC TEMPLATE – Rev. 05/2017]
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1 2. Defendants. [Write each defendant’s full name, address, and phone number.]
2 Defendant 1:
3 Name: _____________________________________________________________
4 Address: _____________________________________________________________
5 Telephone: _____________________________________________________________
6
7 Defendant 2:
8 Name: _____________________________________________________________
9 Address: _____________________________________________________________
10 Telephone: _____________________________________________________________
11
12 Defendant 3:
13 Name: _____________________________________________________________
14 Address: _____________________________________________________________
15 Telephone: _____________________________________________________________
16
17
Defendant 3: _____________________________________________________________
18
Name: _____________________________________________________________
19
Address:
20
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COMPLAINT
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1 2. Defendants. [Write each defendant’s full name, address, and phone number.]
2 Defendant 1:
3 Name: _____________________________________________________________
4 Address: _____________________________________________________________
5 Telephone: _____________________________________________________________
6
7 Defendant 2:
8 Name: _____________________________________________________________
9 Address: _____________________________________________________________
10 Telephone: _____________________________________________________________
11
12 Defendant 3:
13 Name: _____________________________________________________________
14 Address: _____________________________________________________________
15 Telephone: _____________________________________________________________
16
17 JURISDICTION
[Usually only two types of cases can be filed in federal court, cases involving “federal questions”
18 and cases involving “diversity of citizenship.” Check at least one box.]
19 3. My case belongs in federal court
20  under federal question jurisdiction because it is involves a federal law or right.
21 [Which federal law or right is involved?] _____________________________________________
22 _____________________________________________________________________________.
23  under diversity jurisdiction because none of the plaintiffs live in the same state as any of the
24 defendants and the amount of damages is more than $75,000.
25
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COMPLAINT
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1 VENUE
2 [The counties in this District are: Alameda, Contra Costa, Del Norte, Humboldt, Lake, Marin,
Mendocino, Monterey, Napa, San Benito, Santa Clara, Santa Cruz, San Francisco, San Mateo, or
3 Sonoma. If one of the venue options below applies to your case, this District Court is the correct
place to file your lawsuit. Check the box for each venue option that applies.]
4
5 4. Venue is appropriate in this Court because:
6  a substantial part of the events I am suing about happened in this district.
7  a substantial part of the property I am suing about is located in this district.
8  I am suing the U.S. government, federal agency, or federal official in his or her
9 official capacity and I live in this district.
10  at least one defendant is located in this District and any other defendants are
11 located in California.
12
13 INTRADISTRICT ASSIGNMENT
14 [This District has three divisions: (1) San Francisco/Oakland (2) San Jose; and (3) Eureka. First
write in the county in which the events you are suing about happened, and then match it to the
15 correct division. The San Francisco/Oakland division covers Alameda, Contra Costa, Marin, Napa,
16 San Francisco, San Mateo, and Sonoma counties. The San Jose division covers Monterey, San
Benito, Santa Clara, Santa Cruz counties. The Eureka division covers Del Norte, Humboldt, Lake,
17 Mendocino counties, only if all parties consent to a magistrate judge.]
18 5. Because this lawsuit arose in ____________________________ County, it should be

19 assigned to the _____________________________ Division of this Court.
20
21 STATEMENT OF FACTS
22 [Write a short and simple description of the facts of your case. Include basic details such as where
the events happened, when things happened and who was involved. Put each fact into a separate,
23 numbered paragraph, starting with paragraph number 6. Use more pages as needed.]
24
___.______________________________________________________________________
25
_________________________________________________________________________________
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_________________________________________________________________________________
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_________________________________________________________________________________
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_________________________________________________________________________________
COMPLAINT
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1 ____.______________________________________________________________________
2 _________________________________________________________________________________
3 _________________________________________________________________________________
4 _________________________________________________________________________________
5 _________________________________________________________________________________
6 ____. ______________________________________________________________________
7 _________________________________________________________________________________
8 _________________________________________________________________________________
9 _________________________________________________________________________________
10 _________________________________________________________________________________
11 ____. _____________________________________________________________________
12 _________________________________________________________________________________
13 _________________________________________________________________________________
14 _________________________________________________________________________________
15 _________________________________________________________________________________
16 ____. ______________________________________________________________________
17 _________________________________________________________________________________
18 _________________________________________________________________________________
19 _________________________________________________________________________________
20 _________________________________________________________________________________
21 ____. ______________________________________________________________________
22 _________________________________________________________________________________
23 _________________________________________________________________________________
24 _________________________________________________________________________________
25 _________________________________________________________________________________
26 //
27 //
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COMPLAINT
-8-
[Copy this page and insert it where you need additional space.]
1
2 ____. ______________________________________________________________________
3 _________________________________________________________________________________
4 _________________________________________________________________________________
5 _________________________________________________________________________________
6 _________________________________________________________________________________
7 _________________________________________________________________________________
8 ____. ______________________________________________________________________
9 _________________________________________________________________________________
10 _________________________________________________________________________________
11 _________________________________________________________________________________
12 _________________________________________________________________________________
13 _________________________________________________________________________________
14 ____. ______________________________________________________________________
15 _________________________________________________________________________________
16 _________________________________________________________________________________
17 _________________________________________________________________________________
18 _________________________________________________________________________________
19 _________________________________________________________________________________
20 ____. ______________________________________________________________________
21 _________________________________________________________________________________
22 _________________________________________________________________________________
23 _________________________________________________________________________________
24 _________________________________________________________________________________
25 _________________________________________________________________________________
26 ____. ______________________________________________________________________
27 _________________________________________________________________________________
28 _________________________________________________________________________________
COMPLAINT
PAGE ___ OF ___ [JDC TEMPLATE – 05/17]
1 CAUSES OF ACTION
3 To state a claim under 42 U.S.C. § 1983, a plaintiff must allege two essential elements: (1) that a right secured by
4 the Constitution or laws of the United States was violated, and (2) that the alleged violation was committed by a
5 person acting under the color of state law. West v. Atkins, 487 U.S. 42, 48 (1988).
10 First Cause of Action
11 Violation 42 USC 1983, 1st Amendment of US Constitution
12 Whereas the First Amendment States “Congress shall make no law respecting an
13
establishment of religion, or prohibiting the free exercise thereof; or abridging the
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freedom of speech, or of the press; or the right of the people peaceably to assemble,
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and to petition the Government for a redress of grievances.”
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17 Defendants have violated my First Amendment Rights by the following actions
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5 Second Cause of Action
6 Violation 42 USC 1983, 4th Amendment
7 Whereas the 4th Amendment of the United States Constitution states: “The right of the people to be secure in
8 their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not
9 be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation,
10 and particularly describing the place to be searched, and the persons or things to be seized.”
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Defendants have violated my 4th Amendment Rights by the following actions
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2 Third Cause of Action
4 Whereas the 5th Amendment of the United States Constitution States “No person shall be held to answer for a
5 capital, or otherwise infamous crime, unless on a presentment or indictment of a Grand Jury, except in cases arising
6 in the land or naval forces, or in the Militia, when in actual service in time of War or public danger; nor shall any
7 person be subject for the same offence to be twice put in jeopardy of life or limb; nor shall be compelled in any
8 criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of
9 law; nor shall private property be taken for public use, without just compensation.”
10 Defendants have violated my 5th amendment rights by the following actions:
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18 Fourth Cause of Action
20 Whereas the 8th Amendment of the United States Constution States “Excessive bail shall not be required, nor
21 excessive fines imposed, nor cruel and unusual punishments inflicted.”
22 Defendants have violated my Eighth Amendment rights by the following actions:
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28 COMPLAINT
1 Fifth Cause of Action
3 Whereas the 9th Amendment of the United States Constitution states “ The enumeration in the Constitution, of
4 certain rights, shall not be construed to deny or disparage others retained by the people.”
5 Defendants have violated my unenumerated rights which I retain has a human being which are
6
the following:
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Sixth Cause of Action
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Violation 42 USC 1983, 14th Amendment
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Whereas Section I of the 14th Amendment of the United States Consitution states “All persons born or naturalized in
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the United States and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein
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they reside. No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of
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the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor
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deny to any person within its jurisdiction the equal protection of the laws.
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Defendants have violated my 14th amendment rights in the following ways.
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1 Seventh Cause of Action
2 Violation 42 USC 1983, Monell Claim
3 Whereas under the Monell Doctrine spelled out in Monell v. Department of Social Services of the City of New York
4 (436 U.S. 658 (1978)) a government corporation can only be sued under 42 USC 1983 if a civil rights violation is
5 part of a policy or practice of the government corporation. Here a Monel claim is a cause of action because
6 defendants violated my rights under the following policies and practices of defendants:
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18 Eighth Cause of Action
19 42 USC 1985, Conspiracy To Deprive me of my civil rights
20 Whereas 42 USC 1985 holds entities accountable when two or more people to conspire to deprive persons of their
21 civil rights, the following actions of defendants show the violation of my rights was part of a conspiracy
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1 ____.______________________________________________________________________
2 _________________________________________________________________________________
3 _________________________________________________________________________________
4 _________________________________________________________________________________
5 _________________________________________________________________________________
6 ____. ______________________________________________________________________
7 _________________________________________________________________________________
8 _________________________________________________________________________________
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11 ____. _____________________________________________________________________
12 _________________________________________________________________________________
13 _________________________________________________________________________________
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16 ____. ______________________________________________________________________
17 _________________________________________________________________________________
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20 _________________________________________________________________________________
21 ____. ______________________________________________________________________
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23 _________________________________________________________________________________
24 _________________________________________________________________________________
25 _________________________________________________________________________________
26 //
27 //
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COMPLAINT
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1 ____.______________________________________________________________________
2 _________________________________________________________________________________
3 _________________________________________________________________________________
4 _________________________________________________________________________________
5 _________________________________________________________________________________
6 ____. ______________________________________________________________________
7 _________________________________________________________________________________
8 _________________________________________________________________________________
9 _________________________________________________________________________________
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11 ____. _____________________________________________________________________
12 _________________________________________________________________________________
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16 ____. ______________________________________________________________________
17 _________________________________________________________________________________
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21 ____. ______________________________________________________________________
22 _________________________________________________________________________________
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26 //
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COMPLAINT
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1 DEMAND FOR RELIEF

[State what you want the Court to do. Depending on your claims, you may ask the Court to award
2 you money or order the defendant to do something or stop doing something. If you are asking for
money, you can say how much you are asking for and why you should get that amount, or describe
3 the different kinds of harm caused by the defendant.]
4 ____. ______________________________________________________________________
5 _________________________________________________________________________________
6 _________________________________________________________________________________
7 _________________________________________________________________________________
8 _________________________________________________________________________________
9 _________________________________________________________________________________
10 _________________________________________________________________________________
11 _________________________________________________________________________________
12 _________________________________________________________________________________
13 _________________________________________________________________________________
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15 DEMAND FOR JURY TRIAL
16 [Check this box if you want your case to be decided by a jury, instead of a judge, if allowed.]
17  Plaintiff demands a jury trial on all issues.
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20 Respectfully submitted,
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22 Date: Sign Name:
23 Print Name:
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COMPLAINT
PAGE ___ OF ___ [JDC TEMPLATE – 05/17]
1 Your name:
2 Address:
4 Phone Number:
5 Fax Number:
6 E-mail Address:
7 Pro Se [Select one: Plaintiff or Defendant]
10 [Select one location: San Francisco / Oakland / San Jose / Eureka]
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)
12 ) Case Number:
)
13 )
) Emergency Pro Se Application for Temporary
14 ) Restraining Order and Preliminary Injunction
vs. )
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22 I, ____________________ bring this application for a temporary restraining order under Rule 65
23 of Federal Rules of Civil Procedure to enjoin DEFENDANTS (briefly describe what you want
24 the court to do)
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TITLE OF DOCUMENT: CASE NO.:
PAGE NO. OF [JDC TEMPLATE]

1
2 Table of Authorities
3 1. Stuhlbarg Int'l Sales Co., Inc. v. John D. Brush & Co., Inc
4 2. Winter v. Natural Res. Defense Council, Inc., 555 U.S. 7, 20 (2008)
5 3. Alliance for the Wild Rockies v. Cottrell, 632 F.3d 1127, 1134-35 (9th Cir. 2011)
6 4. Monterey Mech. Co. v. Wilson, 125 F.3d 702, 715 (9th Cir. 1997)
7 5. Nelson v. NASA, 530 F.3d 865, 882 (9th Cir. 2008)
8 6. Nat’l Aero. & Space Admin. v. Nelson, 56 U.S. 134 (2011)
9 7. Kennedy v. City of Ridgefield, 439 F.3d 1055, 1062 (9th Cir. 2006
10 8. Munger v. City of Glasgow, 227 F.3d 1082 (9th Cir. 2000)
11 9. White v. Rochford, 592 F.2d 381 (7th Cir. 1989)
12 10. Sylvia Landfield Tr. v. City of L.A., 729 F.3d 1189, 1195 (9th Cir. 2013)
13 11. Martin v. City of Boise, 902 F. 3d 1031, 1048 (9th Cir. 2018).
14 12. LA Alliance For Human Rights vs County of LA 2:20-cv-02291-DOC-KES
15 Related Cases
16 13. Sausalito/Marin County Chapter of the California Homeless Union et al vs City of
17 Sausalito et al 21-cv-01143-EMC
18 14. Marin County Homeless Union et al v. City of Novato et al (4:21-cv-05401)
19 15. Naretto et al v. City of Petaluma et al (3:21-cv-10027)
20
21 Procedural Background
22 1. The standards for a TRO are the same as those for a preliminary injunction. See
23 Stuhlbarg Int'l Sales Co., Inc. v. John D. Brush & Co., Inc., 240 F.3d 832, 839 n.7 (9th
24 Cir. 2001). A plaintiff must demonstrate (1) a likelihood of success on the merits, (2) a
25 likelihood of irreparable harm that will result if an injunction is not issued, (3) the
26 balance of equities tips in favor of the plaintiff, and (4) an injunction is in the public
27 interest. See Winter v. Natural Res. Defense Council, Inc., 555 U.S. 7, 20 (2008). The
28 Ninth Circuit has clarified that its "sliding scale" approach to preliminary injunctive relief

1 is still viable. That is, if the plaintiff can demonstrate the risk of irreparable injury, under
2 the sliding scale test, the strength of the plaintiff's showing on the merits necessary to
3 secure a preliminary injunction varies with the degree to which the balance of hardship
4 tips in its favor. In other words, preliminary injunctive relief "'is appropriate when a
5 plaintiff demonstrates . . . that serious questions going to the merits were raised and the
6 balance of hardships tips sharply in the plaintiff's favor.'" Alliance for the Wild Rockies v.
7 Cottrell, 632 F.3d 1127, 1134-35 (9th Cir. 2011).
9 2. LIKELIHOOD OF SUCCESS ON THE MERITS
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14 3. IRREPARABLE HARM:
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20 4. BALANCE OF EQUITIES:
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25 5. INJUNCTION IS IN THE PUBLIC INTEREST
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1
2 6. Moreover, the Ninth Circuit has held a violation of a person’s constitutional rights may
3 also constitute irreparable injury see Monterey Mech. Co. v. Wilson, 125 F.3d 702, 715
4 (9th Cir. 1997) (noting that “‘an alleged constitutional infringement will often alone
5 constitute irreparable harm’”); Nelson v. NASA, 530 F.3d 865, 882 (9th Cir. 2008)
6 (stating that, “[u]nlike monetary injuries, constitutional violations cannot be adequately
7 remedied through damages and therefore generally constitute irreparable harm”), rev’d
8 on other grounds, Nat’l Aero. & Space Admin. v. Nelson, 56 U.S. 134 (2011).
10 7. CONSTITUTIONAL RIGHTS VIOLATED:
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17 LIKLIHOOD TO SUCCEED ON ITS MERITS AND IRREPARABLE HARM
18 STATE CREATED DANGER DOCTRINE
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20 8. The Ninth Circuit recognizes a substantive due process claim where there is a “state-
21 created danger” – i.e., where a state actor “‘affirmatively place[s] an individual in danger’
22 by acting with ‘deliberate indifference to [a] known or obvious danger in subjecting the
23 plaintiff to it.’” Kennedy v. City of Ridgefield, 439 F.3d 1055, 1062 (9th Cir. 2006); see
24 also id. at 1061 (noting that state action affirmatively places a plaintiff in a position of
25 danger “where state action creates or exposes an individual to a danger which he or she
26 would not have otherwise faced).
27 9. But that is not the only situation where there is a state-created danger. In Kennedy itself,
28 the Ninth Circuit cited to cases where the state-created danger was, effectively, from the

1 environment. See id. at 1061 n.1 (citing White v. Rochford, 592 F.2d 381 (7th Cir. 1989),
2 where “defendants left helpless minor children subject to inclement weather and great
3 physical danger without any apparent justification’”); id. at 1062 (citing Munger v. City
4 of Glasgow, 227 F.3d 1082 (9th Cir. 2000), which held that “police officers could be held
5 liable for the hypothermia death of a visibly drunk patron after ejecting him from a bar on
6 a bitterly cold night”). In this case during COVID-19 Pandemic, the cities threats of
7 evicting me from my campsite also significantly increase my risk of being irreparably
8 harmed or killed by COVID-19 by making it impossible for me to comply with COVID -
9 19 guidelines to shelter in place.
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11 10. HOW THE DEFENDANTS ACTIONS ARE AFFIRMATELY PLACING ME IN DANGER:
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5 11. Furthermore, the balance of hardships tip so far in my favor that it appears to be totally
6 arbitrary. Sylvia Landfield Tr. v. City of L.A., 729 F.3d 1189, 1195 (9th Cir. 2013)
7 (stating that “‘[s]ubstantive due process protects individuals from arbitrary deprivation of
8 their liberty by government’[;] [t]o constitute a violation of substantive due process, the
9 alleged deprivation must ‘shock the conscience and offend the community's sense of fair
10 play and decency’”).
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12 12. HOW DEFENDANTS ACTIONS SHOCK CONSCIENCE AND OFFEND THE
13 COMMUNITY’S SENSE OF FAIR PLAY AND DECENCY
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21 13. Furthermore, the ninth circuit recognizes state-created danger that arises from “private
22 violence.” Id. For example, in Kennedy v. City of Ridgefield, the plaintiff filed suit
23 against a city and a police officer after her neighbor’s son – whom she had told the police
24 had molested her child – shot her and shot and killed her husband. See id. at 1058 (noting
25 that, according to the plaintiff, the officer promised to give notice “prior to any police
26 contact with the Burns family about her allegations” but failed to give advance notice;
27 also, after belatedly telling the plaintiff about his contact with the neighbor, the officer
28

1 gave the assurance that the policy would patrol the area around her house and the
2 neighbor’s house).
7 14. (describe how defendants actions are putting you in danger of violence by law
8 enforcement officers or by private citizens.
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20 Balance of Hardships and Public Interest

21 15. The balance of hardships tips strongly in my favor, since I am currently suffering
22 irreparable harm by DEFENDANTS willful and wanton disregard for my welfare.
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1
2 VERIFICATION
3 I, __________________ the plaintiff in the above case submit attached application for temporary
4 restraining and preliminary injunction order to the court so that can justice can be done in this
5 matter. I also attach the foregoing Index of Exhibits.
6
10
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13 Date: _____________________ Sign Name: _______________________________
14 Print Name: _______________________________
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17 INDEX OF EXHIBITS
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19 A CENTER FOR DISEASE CONTROL GUIDANCE COVID 19 HOMELESSNESS

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COVID-19
Interim Guidance on People Experiencing Unsheltered

Homelessness
Interim Guidance
Updated Feb. 10, 2022
CDC is in the process of reviewing these recommendations to determine how to align current precautions with the CDC’s
new COVID-19 Community Levels recommendations. Updates will be posted here when available.
This interim guidance is based on what is currently known about coronavirus disease 2019 (COVID-19). The Centers for
Disease Control and Prevention (CDC) will update this interim guidance as needed and as additional information
becomes available.
Summary of Recent Changes
Updates as of February 10, 2022
• Updated quarantine and isolation guidance for people experiencing unsheltered homelessness.
• Incorporating recommendations for persons who are up to date on COVID-19 vaccinations.
View previous updates
People experiencing unsheltered homelessness (those sleeping outside or in places not meant for human habitation) may be
at risk for infection when there is community spread of COVID-19. This interim guidance is intended to support response to
COVID-19 by local and state health departments, homelessness service systems, housing authorities, emergency planners,
healthcare facilities, and homeless outreach services. Homeless shelters and other facilities should also refer to the Interim
Guidance for Homeless Shelters.
COVID-19 is caused by a coronavirus. Vaccination is the leading prevention measure to keep clients, outreach sta , and
volunteers from getting sick with COVID-19. COVID-19 vaccines are safe and e ective and are available at no cost to everyone
ages 5 years and older living in the United States, regardless of insurance or immigration status. Learn more about
the Bene ts of Getting a COVID-19 Vaccine. See Interim Guidance for Health Departments: COVID-19 Vaccination
Implementation for People Experiencing Homelessness for more information.
Lack of housing contributes to poor physical and mental health outcomes, and linkages to permanent housing for people
experiencing homelessness should continue to be a priority, while addressing risks associated with the COVID-19 pandemic.
In the context of COVID-19 spread and transmission, the risks associated with sleeping outdoors or in an encampment setting
are di erent than from staying indoors in a congregate setting such as an emergency shelter or other congregate living
facility. Outdoor settings may allow people to increase physical distance between themselves and others. However, sleeping
https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html 1/8
outdoors often does not provide protection from the environment, adequate access to hygiene and sanitation facilities, or
connection to services and healthcare. The balance of risks should be considered for each individual experiencing
unsheltered homelessness.
Community coalition-based COVID-19 prevention and

response
Planning and response to COVID-19 transmission among people experiencing homelessness requires a “whole community”
approach, which means involving partners in the response plan development, with clearly outlined roles and
responsibilities. Table 1 outlines some of the activities and key partners to consider for a whole-community approach.
Table 1: Using a whole-community approach to prepare for COVID-19 among people experiencing homelessness
Connect to community-wide planning
Connect with key partners to make sure that you can all easily communicate with each other while preparing for and
responding to cases. A community coalition focused on COVID-19 planning and response should include:
• Local and state health departments
• Outreach teams and street medicine providers
• Homeless service providers and Continuum of Care leadership
• Emergency management
• Law enforcement
• Healthcare providers
• Housing authorities
• Local government leadership
• Other support services like case management, emergency food programs, syringe service programs, and behavioral
health support
• People with lived experiences of homelessness
People with lived experiences of homelessness can help with planning and response. These individuals can serve as peer
navigators to strengthen outreach and engagement e orts. Develop an advisory board with representation from people
with current or former experiences of homelessness to ensure community plans are e ective.
Identify additional sites and resources
Continuing homeless services during community spread of COVID-19 is critical. Make plans to maintain services for all
people experiencing unsheltered homelessness. Furthermore, clients who are positive for COVID-19 or exposed to
someone with COVID-19 need to have access to services and a safe place to stay, separated from others who are not
infected. To facilitate the continuation of services, community coalitions should identify resources to support people
sleeping outside as well as additional temporary housing, including sites with individual rooms that are able to provide
appropriate services, supplies, and sta ng. Temporary housing sites should include:
• Over ow sites to accommodate shelter decompression and higher shelter demands
• Isolation sites for people who are con rmed to be positive for COVID-19 by laboratory testing
• Quarantine sites for people who are awaiting testing, awaiting test results, or who were exposed to COVID-19
• Protective housing for people who are at increased risk for severe illness from COVID-19
Depending on resources and sta availability, housing options that have individual rooms (such as hotels/motels) and
separate bathrooms should be considered for the over ow, quarantine, and protective housing sites. In addition, plan for
how to connect clients to housing opportunities after they have completed their stay in these temporary sites.
Communication
Outreach workers and other community partners, such as emergency food provision programs or law enforcement, can help
ensure people sleeping outside have access to updated information about COVID-19 and access to services.
• Stay updated on the local level of transmission of COVID-19.
• Build on existing partnerships with peer navigators who can help communicate with others.
• Maintain up-to-date contact information and areas frequented for each client.
• Communicate clearly with people sleeping outside.

- Use health messages and materials developed by credible public health sources, such as your local and state public
health departments or the Centers for Disease Control and Prevention (CDC).
- Post signs in strategic places (e.g., near handwashing facilities) providing information on vaccination, physical
distancing, handwashing, and cough etiquette [322 KB, 1 Page].
- Provide educational materials about COVID-19 for everyone, including people with limited English pro ciency,
people with intellectual or developmental disabilities, and people with hearing or vision impairments.
- Ensure communication with clients about changes in homeless services policies and/or changes in physical location
of services such as food, water, hygiene facilities, regular health care, and behavioral health resources.
• Identify and address potential language, cultural, and disability barriers associated with communicating COVID-19
information to workers, volunteers, and those you serve. Learn more about reaching people of diverse languages and
cultures.
Considerations for outreach sta and volunteers

Sta and volunteer training and policies
• Provide training [1.19 MB, 50 Pages] and educational materials related to COVID-19 for sta and volunteers.
• When possible, minimize face-to-face interactions with clients for sta members who are not up to date on COVID-19
vaccination.
• Develop and use contingency plans for increased absenteeism caused by employee illness or by illness in employees’
family members. These plans might include extending hours, cross-training current employees, or hiring temporary
employees.
• Prepare to support case investigation and contact tracing activities in collaboration with local health departments.
• Regardless of vaccination status, assign outreach sta and volunteers who are at increased risk for severe illness from
COVID-19 to duties that do not require them to interact with clients in person.
• Outreach sta and volunteers should review stress and coping resources for themselves and their clients during this
time.
Sta and volunteer prevention measures
• Encourage sta and volunteers to get vaccinated and boosted as soon as possible and stay up to date on vaccinations.
• Advise sta who are not up to date on COVID-19 vaccination to maintain 6 feet of distance while interacting with clients,
sta , and volunteers, where possible.
• Require outreach sta to wear well- tting masks or respirators when working in public settings or interacting with
clients. They should still maintain a distance of 6 feet from each other and clients, even while wearing masks.
• Encourage outreach sta , regardless of vaccination status, to maintain good hand hygiene by washing hands with soap
and water for at least 20 seconds or using hand sanitizer (with at least 60% alcohol) on a regular basis, including before
and after each client interaction.
• Advise outreach sta , regardless of vaccination status, to avoid handling client belongings. If sta are handling client
belongings, they should use disposable gloves, if available. Make sure to train any sta using gloves to ensure proper
use and ensure they perform hand hygiene before and after use. If gloves are unavailable, sta should perform hand
hygiene immediately after handling client belongings.
• Outreach sta who are checking client temperatures should use a system that creates a physical barrier between the
client and the screener.
- Where possible, screeners should remain behind a physical barrier, such as a glass or plastic window or partition
(e g a car window) that can protect the sta member’s face from respiratory droplets that may be produced if the
(e.g., a car window), that can protect the sta member s face from respiratory droplets that may be produced if the
client sneezes, coughs, or talks.
- If physical distancing or barrier/partition controls cannot be put in place during screening, personal protective
equipment (PPE, e.g., facemask, eye protection [goggles or disposable face shield that fully covers the front and
sides of the face], and a single pair of disposable gloves) can be used when within 6 feet of a client.
• For street medicine or other healthcare professionals, regardless of vaccination status, who are caring for clients with
suspected or con rmed COVID-19 should follow Infection Prevention and Control Recommendations for Healthcare
Personnel During the COVID-19 Pandemic.
• Outreach sta , regardless of vaccination status, who do not interact closely (e.g., within 6 feet) with sick clients and do
not clean client environments do not need to wear PPE.
• Outreach sta , regardless of vaccination status, should launder work uniforms or clothes after use using the warmest
appropriate water setting for the items and dry items completely.
• As long as they don’t provide services within congregate homeless service sites, outreach sta may follow general
population guidance to end isolation or quarantine.
Sta process for outreach
• In the process of conducting outreach, sta should

- Greet clients from a distance of 6 feet and explain that you are taking additional precautions to protect yourself and
the client from COVID-19..
- Wear a well- tting mask or respirator.
- Provide the client with a well- tting mask or respirator.
- Screen clients for symptoms by asking them if they feel as if they have a fever, cough, or other symptoms consistent
with COVID-19.
• Children have similar symptoms to adults and generally have mild illness.
• Older adults and people with underlying medical conditions may have delayed presentation of fever and
respiratory symptoms.
• If medical attention is necessary, use standard outreach protocols to facilitate access to healthcare.
- Continue conversations and provision of information while maintaining 6 feet of distance.
- If at any point you do not feel that you are able to protect yourself or your client from the spread of COVID-19,
discontinue the interaction and notify your supervisor.
Considerations for assisting people experiencing unsheltered

homelessness
Help clients reduce their risk of becoming ill from COVID-19
• Strongly recommend clients receive a COVID-19 vaccine and booster. Be prepared to address common questions about
COVID-19 vaccination and provide information about how to access vaccination.
• Those who are experiencing unsheltered homelessness face several risks to their health and safety. Consider the
balance of these risks when addressing options for decreasing COVID-19 spread.
• Continue linkage to homeless services, housing, medical, mental health, syringe services, and substance use treatment,
including provision of medications for opioid use disorder (e.g., buprenorphine, methadone maintenance, etc.). Use
telemedicine, when possible.
• Some people who are experiencing unsheltered homelessness may be at increased risk of severe illness from COVID-19
due to older age or certain underlying medical conditions, such as chronic lung disease or serious heart conditions.
- Reach out to these clients regularly to ensure they are linked to care as necessary.
- Prioritize providing individual rooms for these clients, where available.
• Recommend that all clients wear well- tting masks or respirators any time they are around other people. Masks should
not be placed on children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise
unable to remove the mask without assistance.
• Provide clients with hygiene materials, where available.

• Discourage clients who are not up to date on COVID-19 vaccination (or have unknown vaccination status) from spending
time in crowded places or gathering in large groups, including locations where food, water, or hygiene supplies are being
distributed.
• Clients who come into close contact with someone with COVID-19 should quarantine away from crowded or congregate
settings for 10 days as much as possible and be tested at least 5 days after their last known close contact, regardless of
their vaccination and booster status, unless directed otherwise by state or local health o cials.
• Clients may follow general population guidance for the end of quarantine in other community settings. For example, if a
client is working in a setting that is not a at higher risk for transmission, they may return to work in accordance with the
general population guidance.
• During crisis situations (i.e., space or sta shortages that threaten the continuity of essential operations), homeless

service providers should consult their state, local, territorial, or tribal health department to consider options for
shortening the duration of quarantine or isolation for clients. Reducing quarantine or isolation duration may be
recommended for groups at lower risk of infection rst (e.g., those who are up to date on their COVID-19 vaccines).
Help link sick clients to medical care
• Regularly assess clients for symptoms.

- Provide anyone who presents with symptoms with a mask.
- Clients who have symptoms may or may not have COVID-19. Make sure they have a place they can safely isolate in
coordination with local health authorities.
- If available, a nurse or other clinical sta can help with clinical assessments. These clinical sta should follow
personal protective measures.
- Facilitate access to non-urgent medical care as needed.

- Use standard outreach procedures to determine whether a client needs immediate medical attention. Emergency
signs include but are not limited to:
• Trouble breathing
• Persistent pain or pressure in the chest
• New confusion or inability to arouse
• Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
- Please refer clients for medical care for any other symptoms that are severe or concerning to you.
- Notify the designated medical facility and transporting personnel that clients might have COVID-19.
• If a client has tested positive for COVID-19

- Use standard outreach procedures to determine whether a client needs immediate medical attention.
- If immediate medical attention is not required, facilitate transportation to an isolation site.
- Notify the designated medical facility and transporting personnel that clients might have COVID-19.
- If medical care is not necessary, and if no other isolation options are available, advise the individual on how to
isolate themselves while e orts are underway to provide additional support.
- Coordinate with the local health department and provide locating information for case investigation and contact
tracing.
- All clients who have symptoms of COVID-19 or receive a positive test result for COVID-19, regardless of their
vaccination and booster status or symptoms, should isolate away from crowded areas or congregate settings for 10
days as much as possible from the date symptoms began or the date of the positive test if they do not have
symptoms, unless directed otherwise by state or local health o cials.
- Clients may follow general population guidance for the end of isolation in other community settings. For example, if
a client is working in a setting that is not at high risk for transmission, they may return to work in accordance with
the general population guidance.
- During isolation, ensure continuation of behavioral health support for people with substance use or mental health
disorders.
- In some situations, for example due to severe untreated mental illness, an individual may not be able to comply
with isolation recommendations. In these cases, community leaders should consult local health authorities to
determine alternative options.
Ensure the client has a safe location to recuperate (e.g., respite care) after isolation requirements are completed,
-
and follow-up to ensure medium- and long-term medical needs are met.
Considerations for encampments

• If individual housing options are not available, allow people who are living unsheltered or in encampments to remain
where they are.
- Clearing encampments can cause people to disperse throughout the community and break connections with
service providers. This increases the potential for infectious disease spread.
• Encourage people staying in encampments to set up their tents/sleeping quarters with at least 12 feet x 12 feet of space
per individual.
- If an encampment is not able to provide su cient space for each person, allow people to remain where they are
but help decompress the encampment by linking those at increased risk for severe illness to individual rooms or
safe shelter.
• Work together with other community organizations and o ces to improve sanitation in encampments.
• Ensure nearby restroom facilities have functional water taps, are stocked with hand hygiene materials (soap, drying
materials) and bath tissue, and remain open to people experiencing homelessness 24 hours per day.
• If toilets or handwashing facilities are not available nearby, assist with providing access to portable latrines with
handwashing facilities for encampments of more than 10 people. These facilities should be equipped with hand sanitizer
(containing at least 60% alcohol).
Considerations for a Long-Term Infection Prevention Strategy

for People Experiencing Unsheltered Homelessness
When community COVID-19 transmission levels change, some communities might consider when to modify the COVID-19
prevention measures described above. Below are several factors to consider before modifying community-level COVID-19
prevention approaches for people experiencing unsheltered homelessness, for example, changing outreach team procedures
or approaches to COVID-19 prevention in encampments. These factors should be considered together; no single factor
should be used alone to decide changes in approach.
These factors should be discussed with local public health partners, community homeless service providers, and people with
lived experience of homelessness. Any modi cations to COVID-19 prevention measures should be conducted in a phased and
exible approach, with careful monitoring of COVID-19 cases in the community. Connecting people experiencing
homelessness to permanent stable housing should continue to be the primary goal.
Community Transmission Levels: What is the incidence of COVID-19 in the community?
The incidence of COVID-19 in the community will in uence the risk of infection for people experiencing unsheltered
homelessness. The CDC COVID Data Tracker has a tool that displays the current level of community transmission at the
county level. Increasing COVID-19 vaccination coverage in the surrounding community is important to help reduce community
transmission, but community vaccination coverage should not be used alone to decide to modify approaches to prevention
among people experiencing unsheltered homelessness.
Vaccination Levels: What proportion of people experiencing unsheltered homelessness in the community are up to date with
COVID-19 vaccination?
Vaccination signi cantly decreases the likelihood of severe disease from the virus that causes COVID-19. People experiencing
unsheltered homelessness who are up to date on COVID-19 vaccination do not need to wear masks unless they are accessing
services in a homeless service facility or in public indoor settings in areas of substantial or high transmission. Although we
know vaccines help protect individuals, there is not enough information available yet to determine a level of vaccination
coverage needed to modify community-level COVID-19 prevention measures. Note: Vaccination status should not be a barrier
to accessing homeless services. COVID-19 vaccinations should not be mandatory to receive homeless services unless required
by state or local health authorities.
Availability of Housing: What is the housing availability in the community?

y g g y y
Any modi cations to approaches to encampments or people experiencing unsheltered homelessness should be conducted
with an awareness of housing availability and homeless service capacity. Closing encampments can lead people to disperse
and result in increased crowding at other encampments or in shelters, which can increase the risk of spreading infectious
disease, including COVID-19. Encampment disbursement should only be conducted as part of a plan to rehouse people living
in encampments, developed in coordination with local homeless service providers and public health partners.
Even if the community decides to modify some infection prevention measures for people experiencing unsheltered
homelessness, continue to maintain the following key components of a sustainable approach to disease prevention and
response.
1. Monitor community transmission of COVID-19 in the area. For the latest updates on county-level transmission of the
virus that causes COVID-19, use this CDC COVID Data Tracker tool.
2. Create exible quarantine and isolation locations that are scalable, in case the number of COVID-19 cases in the
community increases.
3. Keep a minimum set of public health prevention and control procedures in place at all times, including
a. Working together with community organizations to improve sanitation in encampments.
b. Ensuring access to handwashing facilities and supplies.
c. Providing place-based, regular health evaluations and linkages to medical care, including access to COVID-19
vaccination, routine vaccinations, and behavioral health services.
More Information
Considerations for food pantries and food distribution sites
Information for health departments
Guidance for homeless service providers
COVID-19 fact sheets for people experiencing homelessness (at the bottom of the page)
Department of Housing and Urban Development (HUD) COVID-19 resources
CDC’s COVID-19 stress and coping information
What We Can Do To Promote Health Equity | CDC
Toolkit for People Experiencing Homelessness | CDC
Previous Updates
Updates from Previous Content
As of November 4, 2021
• Updated guidance to re ect authorization of COVID-19 vaccines for children ages 5–11.
As of July 7, 2021
• Added information on vaccination for people experiencing unsheltered homelessness
• Updated considerations based on vaccination status
As of June 7, 2021
• Added considerations for developing a long term strategy related to COVID-19 prevention among people
experiencing unsheltered homelessness
As of May 10, 2020
• Revisions to document organization for clarity
• Description of “whole community” approach
• Clari cation of outreach sta guidance
• Clari cation of encampment guidance
Last Updated Feb. 10, 2022
1 Your name:
2 Address:
4 Phone Number:
5 Fax Number:
6 E-mail Address:
7 Pro Se [Select one: Plaintiff or Defendant]
10 [Select one location: San Francisco / Oakland / San Jose / Eureka]
11
)
12 ) Case Number:
)
13 )
) Title of Document:
14 Plaintiff(s), )
) Proposed Order
15 vs. )
)
16 )
)
17 )
)
18 )
)
19 )
)
20 )
)
21 Defendant(s). )
)
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18 Date: _____________________ Sign Name: _______________________________
19 Print Name: _______________________________
20
21
22
23
24
25
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28

1 Your name:
2 Address:
3
4 Phone Number:
5 E-mail Address:
6
7
8
UNITED STATES DISTRICT COURT
10 ) Case Number:
)
11 ) DECLARATION OF [name]
)
12 )
Plaintiff(s), )
13 ) IN SUPPORT OF
vs. )
14 )
15 )
)
16 )
)
17 )
)
18 )
)
19 )
)
20 Defendant(s). )
)
21
22
I, [name]
23
declare as follows:
24
[In the first paragraph, explain who you are and how you are connected to the party or events
25 relevant to the lawsuit. If you are the Plaintiff or Defendant, say so here. If you are a witness,
say how you are involved.]
26
1. I am
27
28
DECLARATION OF _________________________________________ IN SUPPORT OF

_____________________________________________________________________________
CASE NO. ; PAGE ___ OF ___ [JDC TEMPLATE Rev.2015]
1 2. I have personal knowledge of all facts stated in this declaration, and if called to
2 testify, I could and would testify competently thereto.

3 [Write each fact in a separate paragraph. You may only write about facts or occurrences that
you have personal knowledge of or that you personally witnessed. Explain how you know each
4 fact. If you have documents that support your argument, you may attach them to this declaration.
Using a separate paragraph and separate exhibit letter for each document. Explain what the
5 document is and how you know what it is. Example: “3. Attached as Exhibit A is a copy of a
letter that I received from [name] on [date] [by mail].”]
6
7 3.
8
9
10 4.
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13 5.
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6.
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7.
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8.
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26 9.
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_____________________________________________________________________________
1 [Insert this page if you need extra space. Number each paragraph.]
2 ___.
3
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5 ___.
6
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8 ___.
9
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12
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_____________________________________________________________________________
1 ___.
2
3 ___.
4
5
6 ___.
7
8
9 ___.
10
11
12
___.
13
14
15
16 I declare under penalty of perjury under the laws of the United States that the foregoing is
17 true and correct and that this declaration was executed on [date] .
18
19 Signature:
20
Printed name:
21
Address:
22
Phone Number:
23
24
25
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28

_____________________________________________________________________________
Reset Form
2
UNITED STATES DISTRICT COURT
3
NORTHERN DISTRICT OF CALIFORNIA
4
6 Case No. C
7 CONSENT OR DECLINATION
Plaintiff(s) TO MAGISTRATE JUDGE
8 v. JURISDICTION
10 Defendant(s).
11 INSTRUCTIONS: Please indicate below by checking one of the two boxes whether you (if you are the party)
or the party you represent (if you are an attorney in the case) choose(s) to consent or decline magistrate judge
12 jurisdiction in this matter. Sign this form below your selection.
Northern District of California
13
United States District Court
☐ Consent to Magistrate Judge Jurisdiction

14
In accordance with the provisions of 28 U.S.C. § 636(c), I voluntarily consent to have a
15 United States magistrate judge conduct all further proceedings in this case, including trial and
entry of final judgment. I understand that appeal from the judgment shall be taken directly to the
16 United States Court of Appeals for the Ninth Circuit.
17
OR
18
☐ Decline Magistrate Judge Jurisdiction
19
In accordance with the provisions of 28 U.S.C. § 636(c), I decline to have a United States
20
magistrate judge conduct all further proceedings in this case and I hereby request that this case
21 be reassigned to a United States district judge.
22
DATE: ________________ NAME:
23
COUNSEL FOR
24 (OR “PRO SE”):
25
26 Signature
27
28
Instructions: Voluntary Dismissal of a Defendant or the Case
This template was prepared by the Justice & Diversity Center, a nonprofit organization, and is not an official
court form. It can be used in certain civil lawsuits in the Northern District Court of California. This template
provides guidance only. Using this template does not guarantee any result in your case.
This packet provides general guidance about voluntarily dismissing a defendant or the entire case.
Before serving this document, make an appointment for free legal information and advice at one of the Legal
Help Centers.
If the case is assigned to a judge in the San Francisco, Oakland, or Eureka federal courthouse,
do one of the following:

This email is to schedule appointments only-no legal advice is given over email.
If the case is assigned to a judge in the San Jose federal courthouse, do one of the following:

WHEN YOU MAY FILE A NOTICE OF VOLUNTARY DISMISSAL
Generally, a plaintiff has a right to file a Notice of Voluntary Dismissal at any time before the defendant
serves either an answer or a motion for summary judgment. If the defendant you want to dismiss from the
case has filed an answer or motion for summary judgment, you cannot use this form. Make an appointment
with the Legal Help Center (above).
06/22/2017 Intructions: Voluntary Dismissal 1 of 2
WILL YOU BE ALLOWED TO RE-FILE AFTER DISMISSING?
This Notice states that the dismissal will be “without prejudice,” which generally means that you may sue
again on the same claim, if the time to do so has not passed (if the statute of limitations has not passed). But
if this is the second time that you have attempted to sue on this claim (in state or federal court), filing this
Notice will be considered a dismissal “with prejudice,” regardless of the language included in the form.
“With prejudice” means you cannot file another suit based on this claim. If you think you may want to re-
file the case later, make an appointment at the Legal Help Center before dismissing your lawsuit.
HOW TO COMPLETE THIS NOTICE OF VOLUNTARY DISMISSAL TEMPLATE
 Fill in the case information. Fill in all blanks on the first page.
 Review and sign. Read the entire document to make sure it is clear and complete. Sign and date.
 Prepare the Certificate of Service. Each document that you file must be “served” on each other
party, usually by sending it in the mail. Follow the instructions on the Certificate of Service.
 If you are dismissing only certain defendants, follow all Orders and deadlines. The case will
continue if you dismiss only certain defendants. Continue to follow all Court Orders and deadlines.
FILING AND SERVING YOUR NOTICE OF VOLUNTARY DISMISSAL
1. Make copies. Once you the documents are complete, make three copies of each. On one copy of
the documents, write “Chambers” on the top in pen. (If there is more than one plaintiff or
defendant, you will also need one copy for each of them.)
2. File the Notice. Deliver or mail the original plus two copies of the Notice and Certificate to the
Clerk’s Office at the courthouse where the Judge for your case is located. The Clerk will take the
original and one copy. The other copy is for you to keep after it is stamped by the Clerk. If you
file by mail, include a self-addressed, stamped envelope so the Clerk can send your copy back.
3. Serve the Notice. Be sure the Notice and Certificate are served on each party.

1 Your name:
2 Address:
3
4 Phone Number:
5 E-mail Address:
6 Pro se Plaintiff
7
10 Division [check one]:  San Francisco  Oakland  San Jose  Eureka
11
)
12 ) Case Number:
)
13 ) NOTICE OF VOLUNTARY DISMISSAL OF
14 )
Plaintiff, ) [check one]
)
15 vs.
)  THIS ENTIRE CASE
16 )  ONLY DEFENDANT [name]
)
17 ) ________________________________________
)
18 )
)
19 Defendant. ) Hon. ___________________________________
)
20
21 TO THE HONORABLE COURT, ALL PARTIES AND COUNSEL: I am the Plaintiff in this
22 matter and pursuant to Federal Rule of Civil Procedure 41(a)(1)(A)(i), I voluntarily dismiss:
23  this entire case.
24  only Defendant [name] ____________________________________________________.
25 Such dismissal shall be without prejudice, with each side to bear its own costs and fees.
26 Date: Sign Name:
27 Print Name:
28
NOTICE OF VOLUNTARY DISMISSAL

Case No. _________________________________________________________ [JDC TEMPLATE]
1 CERTIFICATE OF SERVICE OF DOCUMENT OTHER THAN COMPLAINT
* You must serve each document you file by sending or delivering to the opposing side. Complete
2 this form, and include it with the document that you file and serve.*
3 1. Case Name: _____________________________ v. ________________________________
4 2. Case Number: _____________________________________________________________
5 3. What documents were served?
6 Notice of Voluntary Dismissal
7 4. How was the document served? [check one]
8 Placed in U.S. Mail
9 Hand-delivered
10 Sent for delivery (e.g., FedEx, UPS)
11 Sent by fax (if the other party has agreed to accept service by fax)
12 5. Who did you send the document to? [Write the full name and contact information for
each person you sent the document.]
13
14 _____________________________________ _____________________________________
15 _____________________________________ _____________________________________
16 _____________________________________ _____________________________________
17 _____________________________________ _____________________________________
18 6. When were the documents sent? ______________________________________________

19 7. Who served the documents? [Whoever puts it into the mail, faxes, delivers or sends for
delivery should sign, and print their name and address. You can do this yourself.]
20
21 I declare under penalty of perjury under the laws of the United States that the foregoing
22 is true and correct.
23 Signature: _____________________________________________________
24 Name: _____________________________________________________
25 Address: _____________________________________
26 _____________________________________
27
28
CERTIFICATE OF SERVICE [JDC TEMPLATE Rev. 05/2017]

Instructions: Voluntary Dismissal of a Defendant or the Case
This template was prepared by the Justice & Diversity Center, a nonprofit organization, and is not an official
court form. It can be used in certain civil lawsuits in the Northern District Court of California. This template
provides guidance only. Using this template does not guarantee any result in your case.
This packet provides general guidance about voluntarily dismissing a defendant or the entire case.
Before serving this document, make an appointment for free legal information and advice at one of the Legal
Help Centers.
If the case is assigned to a judge in the San Francisco, Oakland, or Eureka federal courthouse,
do one of the following:

This email is to schedule appointments only-no legal advice is given over email.
If the case is assigned to a judge in the San Jose federal courthouse, do one of the following:

WHEN YOU MAY FILE A NOTICE OF VOLUNTARY DISMISSAL
Generally, a plaintiff has a right to file a Notice of Voluntary Dismissal at any time before the defendant
serves either an answer or a motion for summary judgment. If the defendant you want to dismiss from the
case has filed an answer or motion for summary judgment, you cannot use this form. Make an appointment
with the Legal Help Center (above).
WILL YOU BE ALLOWED TO RE-FILE AFTER DISMISSING?
This Notice states that the dismissal will be “without prejudice,” which generally means that you may sue
again on the same claim, if the time to do so has not passed (if the statute of limitations has not passed). But
if this is the second time that you have attempted to sue on this claim (in state or federal court), filing this
Notice will be considered a dismissal “with prejudice,” regardless of the language included in the form.
“With prejudice” means you cannot file another suit based on this claim. If you think you may want to re-
file the case later, make an appointment at the Legal Help Center before dismissing your lawsuit.
HOW TO COMPLETE THIS NOTICE OF VOLUNTARY DISMISSAL TEMPLATE
 Fill in the case information. Fill in all blanks on the first page.
 Review and sign. Read the entire document to make sure it is clear and complete. Sign and date.
 Prepare the Certificate of Service. Each document that you file must be “served” on each other
party, usually by sending it in the mail. Follow the instructions on the Certificate of Service.
 If you are dismissing only certain defendants, follow all Orders and deadlines. The case will
continue if you dismiss only certain defendants. Continue to follow all Court Orders and deadlines.
FILING AND SERVING YOUR NOTICE OF VOLUNTARY DISMISSAL
1. Make copies. Once you the documents are complete, make three copies of each. On one copy of
the documents, write “Chambers” on the top in pen. (If there is more than one plaintiff or
defendant, you will also need one copy for each of them.)
2. File the Notice. Deliver or mail the original plus two copies of the Notice and Certificate to the
Clerk’s Office at the courthouse where the Judge for your case is located. The Clerk will take the
original and one copy. The other copy is for you to keep after it is stamped by the Clerk. If you
file by mail, include a self-addressed, stamped envelope so the Clerk can send your copy back.
3. Serve the Notice. Be sure the Notice and Certificate are served on each party.

1 Your name:
2 Address:
3
4 Phone Number:
5 E-mail Address:
6 Pro se Plaintiff
7
10 Division [check one]:  San Francisco  Oakland  San Jose  Eureka
11
)
12 ) Case Number:
)
13 ) NOTICE OF VOLUNTARY DISMISSAL OF
14 )
Plaintiff, ) [check one]
)
15 vs.
)  THIS ENTIRE CASE
16 )  ONLY DEFENDANT [name]
)
17 ) ________________________________________
)
18 )
)
19 Defendant. ) Hon. ___________________________________
)
20
21 TO THE HONORABLE COURT, ALL PARTIES AND COUNSEL: I am the Plaintiff in this
22 matter and pursuant to Federal Rule of Civil Procedure 41(a)(1)(A)(i), I voluntarily dismiss:
23  this entire case.
24  only Defendant [name] ____________________________________________________.
25 Such dismissal shall be without prejudice, with each side to bear its own costs and fees.
26 Date: Sign Name:
27 Print Name:
28
NOTICE OF VOLUNTARY DISMISSAL

Case No. _________________________________________________________ [JDC TEMPLATE]
1 CERTIFICATE OF SERVICE OF DOCUMENT OTHER THAN COMPLAINT
* You must serve each document you file by sending or delivering to the opposing side. Complete
2 this form, and include it with the document that you file and serve.*
3 1. Case Name: _____________________________ v. ________________________________
4 2. Case Number: _____________________________________________________________
5 3. What documents were served?
6 Notice of Voluntary Dismissal
7 4. How was the document served? [check one]
8 Placed in U.S. Mail
9 Hand-delivered
10 Sent for delivery (e.g., FedEx, UPS)
11 Sent by fax (if the other party has agreed to accept service by fax)
12 5. Who did you send the document to? [Write the full name and contact information for
each person you sent the document.]
13
14 _____________________________________ _____________________________________
15 _____________________________________ _____________________________________
16 _____________________________________ _____________________________________
17 _____________________________________ _____________________________________
18 6. When were the documents sent? ______________________________________________

19 7. Who served the documents? [Whoever puts it into the mail, faxes, delivers or sends for
delivery should sign, and print their name and address. You can do this yourself.]
20
21 I declare under penalty of perjury under the laws of the United States that the foregoing
22 is true and correct.
23 Signature: _____________________________________________________
24 Name: _____________________________________________________
25 Address: _____________________________________
26 _____________________________________
27
28
CERTIFICATE OF SERVICE [JDC TEMPLATE Rev. 05/2017]

1 NAME
ADDRESS
2 CITY, ST ZIP CODE
PHONE
3 EMAIL
4
UNITED STATES COURT
5
DISTRICT OF NORTHERN CALIFORNIA
6
Case No.:
7
8
PROOF OF SERVICE
9
Plaintiff,
10
vs.
11
12
13
Defendant
14
15
16
17 I,____________________________________ declare that I am a resident of the State of
18 California, over the age of eighteen years, and not a party to the within action. My address is
19 ______________________________
20
21
22 On [date] ____________ I served the following document(s):
23 [List all Documents You Served]
24
25
26
27
28
PROOF OF SERVICE - 1
1 I served these documents by the following means:
3 ( ) By electronic mail by sending a Portable Document Format ("PDF") file to the email
4 addresses of counsel listed above pursuant to stipulation of the parties.
5 ( ) By first class mail by placing a true copy thereof in a sealed envelope with postage thereon
6 fully prepaid and placing the envelope in the firm's daily mail processing center for mailing in the United States mail
7 at {geographic location of post office]_____________________________
8 ( ) By overnight delivery: I enclosed the documents in an envelope or package provided by an
9 overnight delivery carrier and addressed to the persons at the addresses listed above. I placed the envelope or
10 package for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery
11 carrier.
12 ( ) By personal service by causing to be personally delivered a true copy thereof to the address(es)
13 listed herein at the location listed herein.
14
15 I declare under penalty of perjury under the laws of the United States of America that the
16 foregoing is true and correct.
17
18 Executed on [Date] in [geographic location you are in]________________
19 Estoppel
20
21
22
23
24
25
26
27
28
1 NAME
ADDRESS
2 CITY, ST ZIP CODE
PHONE
3 EMAIL
4
UNITED STATES COURT
5
DISTRICT OF NORTHERN CALIFORNIA
6
Case No.:
7
8
PROOF OF SERVICE
9
Plaintiff,
10
vs.
11
12
13
Defendant
14
15
16
17 I,____________________________________ declare that I am a resident of the State of
18 California, over the age of eighteen years, and not a party to the within action. My address is
19 ______________________________
20
21
22 On [date] ____________ I served the following document(s):
23 [List all Documents You Served]
24
25
26
27
28
1 I served these documents by the following means:
3 ( ) By electronic mail by sending a Portable Document Format ("PDF") file to the email
4 addresses of counsel listed above pursuant to stipulation of the parties.
5 ( ) By first class mail by placing a true copy thereof in a sealed envelope with postage thereon
6 fully prepaid and placing the envelope in the firm's daily mail processing center for mailing in the United States mail
7 at {geographic location of post office]_____________________________
8 ( ) By overnight delivery: I enclosed the documents in an envelope or package provided by an
9 overnight delivery carrier and addressed to the persons at the addresses listed above. I placed the envelope or
10 package for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery
11 carrier.
12 ( ) By personal service by causing to be personally delivered a true copy thereof to the address(es)
13 listed herein at the location listed herein.
14
15 I declare under penalty of perjury under the laws of the United States of America that the
16 foregoing is true and correct.
17
18 Executed on [Date] in [geographic location you are in]________________
19 Estoppel
20
21
22
23
24
25
26
27
28

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JS-CAND 44 (Rev.

IV. NATURE OF SUIT (Place an “X” in One Box Only)

V. ORIGIN (Place an “X” in One Box Only)

VIII. RELATED CASE(S), JUDGE DOCKET NUMBER

DATE SIGNATURE OF ATTORNEY OF RECORD

INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS-CAND 44

HOW TO GET LEGAL INFORMATION AND ADVICE

Sign up in the appointment book at either:

Monday to Thursday 9:00 am - 12:00 pm, drop in at

HOW TO COMPLETE THIS COMPLAINT TEMPLATE

7. Identify your demands.

FILING AND SERVING YOUR DOCUMENTS

TIMELINE: FIRST STEPS IN A CIVIL CASE

Complaint, Summons, Attend conference with

UNDERSTANDING THE LAWS AND RULES

18 5. Because this lawsuit arose in ____________________________ County, it should be

10 First Cause of Action

11 Violation 42 USC 1983, 1st Amendment of US Constitution

17 Defendants have violated my First Amendment Rights by the following actions

5 Second Cause of Action

6 Violation 42 USC 1983, 4th Amendment

2 Third Cause of Action

3 Violation 42 USC 1983, 5th Amendment

10 Defendants have violated my 5th amendment rights by the following actions:

18 Fourth Cause of Action

19 Violation 42 USC 1983, 8th Amendment

21 excessive fines imposed, nor cruel and unusual punishments inflicted.”

22 Defendants have violated my Eighth Amendment rights by the following actions:

2 Violation 42 USC 1983, 9th Amendment

2 Violation 42 USC 1983, Monell Claim

18 Eighth Cause of Action

19 42 USC 1985, Conspiracy To Deprive me of my civil rights

1 DEMAND FOR RELIEF

7 Pro Se [Select one: Plaintiff or Defendant]

8 UNITED STATES DISTRICT COURT

9 NORTHERN DISTRICT OF CALIFORNIA

10 [Select one location: San Francisco / Oakland / San Jose / Eureka]

24 the court to do)

PAGE NO. OF [JDC TEMPLATE]

4 2. Winter v. Natural Res. Defense Council, Inc., 555 U.S. 7, 20 (2008)

7 5. Nelson v. NASA, 530 F.3d 865, 882 (9th Cir. 2008)

8 6. Nat’l Aero. & Space Admin. v. Nelson, 56 U.S. 134 (2011)

10 8. Munger v. City of Glasgow, 227 F.3d 1082 (9th Cir. 2000)

11 9. White v. Rochford, 592 F.2d 381 (7th Cir. 1989)

14 12. LA Alliance For Human Rights vs County of LA 2:20-cv-02291-DOC-KES

16 13. Sausalito/Marin County Chapter of the California Homeless Union et al vs City of

18 14. Marin County Homeless Union et al v. City of Novato et al (4:21-cv-05401)

19 15. Naretto et al v. City of Petaluma et al (3:21-cv-10027)

PAGE NO. OF [JDC TEMPLATE]

7 Cottrell, 632 F.3d 1127, 1134-35 (9th Cir. 2011).

9 2. LIKELIHOOD OF SUCCESS ON THE MERITS

25 5. INJUNCTION IS IN THE PUBLIC INTEREST

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6 (stating that, “[u]nlike monetary injuries, constitutional violations cannot be adequately

10 7. CONSTITUTIONAL RIGHTS VIOLATED:

17 LIKLIHOOD TO SUCCEED ON ITS MERITS AND IRREPARABLE HARM

18 STATE CREATED DANGER DOCTRINE

26 would not have otherwise faced).

13 Date: _ Sign Name: ___________

18 Date: _ Sign Name: ___________