{"id":11517,"date":"2023-08-29T19:35:27","date_gmt":"2023-08-29T19:35:27","guid":{"rendered":"https:\/\/lawsuitlegit.com\/?p=11517"},"modified":"2023-09-05T23:47:26","modified_gmt":"2023-09-05T23:47:26","slug":"short-form-complaint-for-camp-lejeune-water-lawsuits-proposed","status":"publish","type":"post","link":"https:\/\/lawsuitlegit.com\/short-form-complaint-for-camp-lejeune-water-lawsuits-proposed\/","title":{"rendered":"Short Form Complaint for Camp Lejeune Water Lawsuits – Proposed"},"content":{"rendered":"

Short Form Complaint - Camp Lejeune Water Lawsuits<\/a>
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EXHIBIT D<\/p>\n

Case 7:23-cv-00897-RJ Document 17-4 Filed 08\/28\/23 Page 1 of 6
\nIN THE UNITED STATES DISTRICT COURT
\nFOR THE EASTERN DISTRICT OF NORTH CAROLINA
\nSOUTHERN DIVISION
\nNo. ___________<\/p>\n

IN RE: CAMP LEJEUNE
\nWATER LITIGATION<\/p>\n

__________________________________\/<\/p>\n

THIS DOCUMENT RELATES TO: JURY TRIAL DEMANDED<\/p>\n

C<\/p>\n

Plaintiff First Middle Last Suffix<\/p>\n

SHORT-FORM COMPLAINT<\/p>\n

The Plaintiff named below, or Plaintiff\u2019s representative, files this Short Form Complaint<\/p>\n

against Defendant United States of America under the Camp Lejeune Justice Act of 2022<\/p>\n

(\u201cCLJA\u201d). Pub. L. No. 117-168, \u00a7 804, 136 Stat. 1802, 1802\u201304 (2022). Plaintiff or Plaintiff\u2019s<\/p>\n

representative incorporates by reference the allegations contained in the Master Complaint (DE<\/p>\n

____) on file in the case styled In Re: Camp Lejeune Water Litigation, Case No. 7:23-cv-897, in<\/p>\n

the United States District Court for the Eastern District of North Carolina. Plaintiff or Plaintiff\u2019s<\/p>\n

representative files this Short-Form Complaint as permitted by Pretrial Order No. __.<\/p>\n

Plaintiff or Plaintiff\u2019s representative alleges as follows:<\/p>\n

I. INSTRUCTIONS<\/p>\n

1. On THIS FORM, are you asserting a claim for This form may only be used to file a complaint for
\ninjuries to YOU or to SOMEONE ELSE you legally ONE PERSON\u2019S injuries. If you intend to bring
\nrepresent? claims for multiple individuals\u2019 injuries\u2014for example,
\n\u2610 To me a claim for yourself and one for a deceased spouse\u2014
\n\u2610 Someone else you must file ONE FORM FOR EACH INJURED
\nPERSON.<\/p>\n

Case 7:23-cv-00897-RJ Document 17-4 Filed 08\/28\/23 Page 2 of 6
\n-1-
\nII. PLAINTIFF INFORMATION<\/p>\n

If you checked \u201cTo me\u201d in Box 1, YOU are the Plaintiff. Complete this section with information about YOU.<\/p>\n

If you checked \u201cSomeone else\u201d in Box 1, THAT PERSON is the Plaintiff. Complete this section with
\ninformation about THAT PERSON.<\/p>\n

2. First name: 3. Middle name: 4. Last name: 5. Suffix:<\/p>\n

6. Sex: 7. Is the Plaintiff deceased?
\n\u2610 Male \u2610 Yes
\n\u2610 Female \u2610 No
\n\u2610 Other
\nIf you checked \u201cTo me\u201d in Box 1, check \u201cNo\u201d here.
\nSkip (8) and (9) if you checked \u201cYes\u201d in Box 7.
\n8. Residence city: 9. Residence state:<\/p>\n

Skip (10), (11), and (12) if you checked \u201cNo\u201d in Box 7.
\n10. Date of Plaintiff\u2019s 11. Plaintiff\u2019s residence 12. Was the Plaintiff\u2019s death caused by an injury
\ndeath: state at the time of their that resulted from their exposure to contaminated
\ndeath: water at Camp Lejeune?
\n\u2610 Yes
\n\u2610 No<\/p>\n

III. EXPOSURE INFORMATION<\/p>\n

If you checked \u201cTo me\u201d in Box 1, complete this section with information about YOU.<\/p>\n

If you checked \u201cSomeone else\u201d in Box 1, complete this section with information about THAT PERSON.<\/p>\n

13. Plaintiff\u2019s first month of exposure to the water 14. Plaintiff\u2019s last month of exposure to the water at
\nat Camp Lejeune: Camp Lejeune:<\/p>\n

15. Estimated total months of exposure: 16. Plaintiff\u2019s status at the time(s) of exposure
\n(please check all that apply):
\n\u2610 Member of the Armed Services
\n\u2610 Civilian (includes in utero exposure)
\n17. If you checked Civilian in Box 16, check all that 18. Did Plaintiff at any time live or work in any of
\ndescribe the Plaintiff at the time(s) of exposure: the following areas? Check all that apply.
\n\u2610 Civilian Military Dependent \u2610 Berkeley Manor
\n\u2610 Civilian Employee of Private Company \u2610 Hadnot Point
\n\u2610 Civil Service Employee \u2610 Hospital Point
\n\u2610 In Utero\/Not Yet Born \u2610 Knox Trailer Park
\n\u2610 Other \u2610 Mainside Barracks
\n\u2610 Midway Park
\n\u2610 Paradise Point
\n\u2610 Tarawa Terrace
\n\u2610 None of the above
\n\u2610 Unknown<\/p>\n

Case 7:23-cv-00897-RJ Document 17-4 Filed 08\/28\/23 Page 3 of 6
\n-2-
\nIV. INJURY INFORMATION<\/p>\n

If you checked \u201cTo me\u201d in Box 1, complete this section with information about YOU.<\/p>\n

If you checked \u201cSomeone else\u201d in Box 1, complete this section with information about THAT PERSON.<\/p>\n

19. Identify the illnesses or conditions the Plaintiff suffered as a result of exposure to contaminated water at
\nCamp Lejeune.<\/p>\n

Injury Approximate date of onset
\n\u2610 Adverse birth outcomes (Plaintiff is the PARENT of an individual who died in
\nutero or was stillborn or born prematurely)
\n\u2610 ALS (Lou Gehrig\u2019s Disease)
\n\u2610 Aplastic anemia or myelodysplastic syndrome
\n\u2610 Bile duct cancer
\n\u2610 Bladder cancer
\n\u2610 Brain \/ central nervous system cancer
\n\u2610 Breast cancer
\n\u2610 Cardiac birth defects (Plaintiff was BORN WITH the defects)
\n\u2610 Cervical cancer
\n\u2610 Colorectal cancer
\n\u2610 Esophageal cancer<\/a>
\n\u2610 Gallbladder cancer
\n\u2610 Hepatic steatosis (Fatty Liver Disease)
\n\u2610 Hypersensitivity skin disorder
\n\u2610 Infertility
\n\u2610 Intestinal cancer
\n\u2610 Kidney cancer
\n\u2610 Non-cancer kidney disease
\n\u2610 Leukemia
\n\u2610 Liver cancer
\n\u2610 Lung cancer
\n\u2610 Mutliple myeloma
\n\u2610 Neurobehavioral effects
\n\u2610 Non-cardiac birth defects (Plaintiff was BORN WITH the defects)
\n\u2610 Non-Hodgkin\u2019s Lymphoma
\n\u2610 Ovarian cancer
\n\u2610 Pancreatic cancer
\n\u2610 Parkinson\u2019s disease
\n\u2610 Prostate cancer
\n\u2610 Sinus cancer
\n\u2610 Soft tissue cancer
\n\u2610 Systemic sclerosis \/ scleroderma
\n\u2610 Thyroid cancer<\/p>\n

Case 7:23-cv-00897-RJ Document 17-4 Filed 08\/28\/23 Page 4 of 6
\n-3-
\nThe Camp Lejeune Justice Act does not specify a list of covered conditions.<\/p>\n

If the Plaintiff suffers or previously suffered from a condition not listed above, and the Plaintiff alleges that the
\ncondition was caused by exposure to the water at Camp Lejeune as required under the Act, please check \u201cOther\u201d
\nand describe the condition on the following lines.<\/p>\n

Note in particular that the Board of Veterans\u2019 Appeals of the U.S. Department of Veterans Affairs (the \u201cVA\u201d)
\nhas approved benefits in connection with Camp Lejeune for conditions beyond those listed above.
\n\u2610 Other: Approximate date of onset
\n________________________________________________________________ _____________________<\/p>\n

________________________________________________________________ _____________________<\/p>\n

________________________________________________________________ _____________________<\/p>\n

________________________________________________________________ _____________________<\/p>\n

V. REPRESENTATIVE INFORMATION<\/p>\n

If you checked \u201cTo me\u201d in Box 1, SKIP THIS SECTION and proceed to section VI. (\u201cExhaustion\u201d).<\/p>\n

If you checked \u201cSomeone else\u201d in Box 1, complete this section with information about YOU.<\/p>\n

20. Representative First 21. Representative 22. Representative Last 23. Representative
\nName: Middle Name: Name: Suffix:<\/p>\n

24. Residence City: 25. Residence State:<\/p>\n

\u2610 Outside of the U.S.<\/p>\n

26. Representative Sex:
\n\u2610 Male
\n\u2610 Female
\n\u2610 Other<\/p>\n

27. What is your familial relationship to the Plaintiff?
\n\u2610 They are\/were my spouse.
\n\u2610 They are\/were my parent.
\n\u2610 They are\/were my child.
\n\u2610 They are\/were my sibling.
\n\u2610 Other familial relationship: They are\/were my _____________
\n\u2610 No familial relationship.
\nDerivative claim
\n28. Did the Plaintiff\u2019s death or injury cause the Plaintiff\u2019s spouse, children, or parents mental anguish, loss
\nof financial support, loss of consortium, or any other economic or non-economic harm for which you
\nintend to seek recovery?
\n\u2610 Yes
\n\u2610 No<\/p>\n

Case 7:23-cv-00897-RJ Document 17-4 Filed 08\/28\/23 Page 5 of 6
\n-4-
\nVI. EXHAUSTION<\/p>\n

29. On what date was the administrative claim for 30. What is the DON Claim Number for the
\nthis Plaintiff filed with the Department of the Navy administrative claim?
\n(DON)?
\n____________________
\nmm\/dd\/yyyy
\n\u2610 DON has not yet assigned a Claim Number<\/p>\n

VII. CLAIM FOR RELIEF<\/p>\n

Plaintiff respectfully requests that pursuant to subsection 804(b) of the CLJA the Court<\/p>\n

enter judgment against the Defendant and award damages and all other appropriate relief for the<\/p>\n

harm to Plaintiff that was caused by exposure to the water at Camp Lejeune.<\/p>\n

VIII. JURY TRIAL DEMAND<\/p>\n

Plaintiff demands a trial by jury of all issues so triable pursuant to Rule 38 of the Federal<\/p>\n

Rules of Civil Procedure and subsection 804(d) of the CLJA.<\/p>\n

Dated: mm\/dd\/yyyy<\/p>\n

[Signature block]<\/p>\n

Case 7:23-cv-00897-RJ Document 17-4 Filed 08\/28\/23 Page 6 of 6
\n-5-<\/p>\n","protected":false},"excerpt":{"rendered":"Short Form Complaint – Camp Lejeune Water Lawsuits EXHIBIT D Case 7:23-cv-00897-RJ Document 17-4 Filed 08\/28\/23 Page 1 of 6 IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF NORTH CAROLINA SOUTHERN DIVISION No. ___________ IN RE: CAMP LEJEUNE WATER LITIGATION __________________________________\/ THIS DOCUMENT RELATES TO: JURY TRIAL DEMANDED C Plaintiff First Middle… View Article<\/a>","protected":false},"author":1,"featured_media":13937,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[501,197,198],"tags":[],"acf":[],"_links":{"self":[{"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/posts\/11517"}],"collection":[{"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/comments?post=11517"}],"version-history":[{"count":9,"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/posts\/11517\/revisions"}],"predecessor-version":[{"id":18393,"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/posts\/11517\/revisions\/18393"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/media\/13937"}],"wp:attachment":[{"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/media?parent=11517"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/categories?post=11517"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/lawsuitlegit.com\/wp-json\/wp\/v2\/tags?post=11517"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}