Sample Civil Complaint Form printable pdf download

COMMONWEALTH OF PENNSYLVANIA

CIVIL COMPLAINT

COUNTY OF:

Magisterial District Number:

PLAINTIFF:

NAME and ADDRESS

List your name and address here

MDJ Name: Hon

MDJ information can

Address:

be found at

VS.

(

)

Telephone:

DEFENDANT:

NAME and ADDRESS

List your employer's name &

address here

Docket No.:

Date Filed:

AMOUNT

DATE PAID

FILING COSTS

POSTAGE

Social security numbers and financial information

SERVICE COSTS

(e.g. PINS) should not be listed. If the identity of an

account number must be established, list only the

CONSTABLE ED.

last four digits. 204 Pa.Code §§ 213.1 - 213.7.

TOTAL

Pa.R.C.P.D.J. No. 206 sets forth those costs recoverable by the prevailing party.

Enter Amount

TO THE DEFENDANT:

The above named plaintiff(s) asks judgment against you for $

together with costs

upon the following claim:

Plaintiff was employed by Defendant from January 2010 September 2010. During that time, Plaintiff was

to be paid an hourly wage of $8.00. Plaintiff was a full time employee working 40 hours/week.

Defendant failed to provide Plaintiff with a paycheck for the pay period covering 9/1/10 9/14/10. In this

two week period, Plaintiff worked 80 hours and should have been paid $640. Plaintiff is requesting the full

amount of wages earned pursuant to the terms of her employment agreement.

Print your name here

verify that the facts set forth in this complaint are true and correct to the

best of my knowledge, information, and belief. This statement is made subject to the penalties of Section 4904 of the Crimes

Code (18 PA. C.S. § 4904) related to unsworn falsification to authorities.

Sign here

Signature of Plaintiff or Authorized Agent)

(

The plaintiff’s attorney shall file an entry of appearance with the magisterial district court pursuant to Pa.R.C.P.M.D.J. 207.1.

IF YOU INTEND TO ENTER A DEFENSE TO THIS COMPLAINT, YO U SHOULD SO NOTIFY THIS OFFICE IMMEDIATELY AT THE

ABOVE TELEPHONE NUMBER. YOU MUST APPEAR AT THE HEARING AND PRESENT YOUR DEFENSE. UNLESS YOU DO,

JUDGMENT MAY BE ENTERED AGAINST YOU BY DEFAULT.

If you have a claim against the plaintiff which is within magisterial district judge jurisdiction and which you intend

to assert at the hearing, you must file it on a complaint form at this office at least five (5) days before the date set

for the hearing.

If you are disabled and require a reasonable accommodation to gain access to the Magisterial District

Court and its services, please contact the Magisterial District Court at the above address or telephone

number. We are unable to provide transportation.

AOPC 308A-11

Sample Civil Complaint Form

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