Pro Se 4

Complaint for a Civil Case Alleging Breach of Contract

Agency
U.S. Courts
Revision
Rev. 12/16
Fillable fields
77
Pages
5
Official source
U.S. Courts form page
Checked
October 20, 2026
Fill Pro Se 4 online
Page 1 of form Pro Se 4

Pro Se 4: Complaint for a Civil Case Alleging Breach of Contract

Pro Se 4, Complaint for a Civil Case Alleging Breach of Contract, is a pleading form from the U.S. Courts for a civil case in a United States district court. Its heading cites 28 U.S.C. § 1332 and diversity of citizenship. It is one of the Civil Pro Se Forms, which the U.S. Courts page says are limited to types of cases often filed in federal courts by people who represent themselves or who may not have much experience in federal courts.

The 5-page form asks for the parties, how the diversity of citizenship requirements are met, a statement of the agreement or contract and how the defendant failed to comply, the relief requested, and a signed certification under Federal Rule of Civil Procedure 11. The page notes that no form provides legal advice or substitutes for having or consulting a lawyer, and that a court may require more or less information than a form asks for.

The U.S. Courts offers it as a PDF and a Word file, effective on December 1, 2016. This page explains the form in plain words and is not legal advice. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Pro Se 4: Complaint for a Civil Case Alleging Breach of Contract, as printed by COURTS

What's on Pro Se 4

Caption

The district and division, the full name of each plaintiff and defendant, a yes or no choice for a jury trial, and a case number left for the Clerk's Office. Names that do not fit go on an attached page, with "see attached" written in the space.

I. The Parties

Name, address, phone and email for each plaintiff, and for each defendant, whether an individual, government agency, organization or corporation, with an individual's job or title if known. There is room for four defendants.

II. Basis for Jurisdiction

Diversity of citizenship under 28 U.S.C. § 1332: each plaintiff's and defendant's State or nation of citizenship, or place of incorporation and principal place of business, and an explanation of why the amount in controversy is more than $75,000.

III. Statement of Claim

Who made the agreement or contract and on what date, whether it was oral or written, what it required each party to do, and what the defendant did or failed to do. A printed line states that the plaintiff has complied with the plaintiff's obligations under the contract.

IV. Relief

The damages or other relief asked for, any basis for saying the wrongs are continuing, the amounts of actual damages and their basis, and any punitive or exemplary damages with amounts and reasons.

V. Certification and Closing

A certification under Federal Rule of Civil Procedure 11, then the date, signature and printed name of the plaintiff, or the attorney's details.

How to fill out Pro Se 4

  1. 1

    Read the notes on the form page

    The U.S. Courts page says no form provides legal advice, a court may require more or less than a form asks, and to consult the rules and caselaw that govern in the court where you file.

  2. 2

    Fill in the caption and parties

    Enter the district, division and the full names of the parties, choose yes or no for a jury trial, and leave the case number for the Clerk's Office.

  3. 3

    Explain the basis for jurisdiction

    Section II asks how the diversity of citizenship requirements have been met, with an extra page for each additional plaintiff or defendant.

  4. 4

    Describe the contract and the relief

    The form asks for short and plain statements, without legal arguments, in sections III and IV, including the date of the agreement and what each party was required to do. Attach pages if needed.

  5. 5

    Leave out private details

    The page cites Federal Rule of Civil Procedure 5.2: a filing may show only the last four digits of a Social Security, taxpayer or financial account number, the year of birth, and a minor's initials.

  6. 6

    Sign and date

    Sign under the Rule 11 certification and print your name. Parties without an attorney also agree to keep their address current with the Clerk's Office.

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Court, timing and help

Court

The form is captioned for a United States District Court, district and division. The page says to consult the rules and caselaw that govern in the court where the pleading is filed.

Fees

The form and its page do not print a filing fee.

Timing

The page says the forms give no guidance on when pleadings, claims or defenses have to be raised or who has to be sued, and that some have to be raised within a certain period of time.

A lawyer

The page says that if you are not a lawyer and are suing or have been sued, it is best to have or consult a lawyer if possible.

Formats

The U.S. Courts page offers Pro Se 4 as a PDF and as a Word document.

Who uses Pro Se 4?

  • People representing themselves

    Section V.A is for parties without an attorney. They agree to tell the Clerk's Office about any address change, and the form says a missing current address may result in dismissal of the case.

  • Individual plaintiffs

    Section II.A.1 asks for the State of which an individual plaintiff is a citizen. The form says that in a diversity of citizenship case, no defendant may be a citizen of the same State as any plaintiff.

  • Corporate plaintiffs

    Section II.A.2 asks for the State under whose laws a corporate plaintiff is incorporated and the State of its principal place of business.

  • Attorneys

    Section V.B has a signature block for an attorney, with bar number, law firm, address, phone and email.

The plaintiff, or the plaintiff's attorney, fills out and signs Pro Se 4, and the Clerk's Office fills in the case number. The page describes the Civil Pro Se Forms as examples for people who represent themselves or have little experience in federal courts.

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Questions about Form Pro Se 4

Is Pro Se 4 legal advice?

No. The U.S. Courts page says no form provides legal advice or substitutes for having or consulting a lawyer, and that following a form does not guarantee a pleading is legally or factually correct or sufficient.

What basis for jurisdiction does Pro Se 4 use?

Its heading cites 28 U.S.C. § 1332 and diversity of citizenship. Section II says federal courts may hear cases in which a citizen of one State sues a citizen of another State or nation and the amount at stake is more than $75,000, and asks how these requirements have been met.

What does the statement of claim ask about the contract?

Section III asks for the parties to the agreement or contract, the date it was made, whether it was oral or written, what it required each party to do, and what the defendant did or failed to do that did not comply with it.

Who fills in the case number?

The form says the case number is filled in by the Clerk's Office.

What personal details does a complaint leave out?

The page cites Federal Rule of Civil Procedure 5.2: filings should not contain anyone's full Social Security number or full birth date, the name of a person known to be a minor, or a complete financial account number.

Does Pro Se 4 say when to file?

No. The page says the forms give no guidance on timing, that some pleadings, claims or defenses have to be raised within a certain period of time, and that the Federal Rules of Civil Procedure are available free at www.uscourts.gov.