1Full (first, middle, and last) name of Plaintiff injured/deceased due to use of GLP- 1 RA Product(s): ______________________________________________________________.
2If applicable, full name(s) and representative capacity of Plaintiff(s) alleging wrongful death claim: ___________________________________________________________, as ___________________________ of the estate of ___________________________, deceased.
3If applicable, full name(s) of Plaintiff(s) alleging survival claims, as permitted under state law(s): ______________________________________________________________.
4If applicable, full name(s) of Plaintiff(s) alleging loss of consortium or loss of services: ______________________________________________________________________. Defendant(s)
5Plaintiff(s)/Decedent’s Representative is/are suing the following Defendant(s) (check all that apply):
_____ Novo Nordisk Inc. _____ Novo Nordisk A/S _____ Eli Lilly and Company _____ Lilly USA, LLC _____ other(s) (identify): ___________________________________________
Kevin Haynes JURISDICTION AND VENUE
6City and state of Plaintiff(s)’ current residence (or in a case brought on behalf of a Decedent, Decedent’s last permanent residence):
7State where Plaintiff/Decedent was prescribed the GLP-1RA Product(s) at issue:
8State of Plaintiff’s/Decedent’s residence at time of their use of the GLP-1RA Product(s) at issue:
9City and state of Plaintiff(s)’/Decedent’s residence at time of diagnosis of injury:
10Jurisdiction is based on: _____ diversity of citizenship pursuant to 28 U.S.C. § 1332 _____ other (plead in sufficient detail as required by applicable rules):
11The District Court(s) where Plaintiff(s) might have otherwise filed this Short Form Complaint, absent this Court’s CMO No. 14, and/or to where remand could be ordered:
12Venue is proper in the District Court identified in Paragraph 11 because: _____ a substantial part of the events and omissions giving rise to Plaintiff(s)’
claims occurred there
Dallas, Texas Texas Texas Dallas, Texas Northern District of Texas _____ other (plead in sufficient detail as required by applicable rules):
13If applicable, identify the citizenship of any additional Defendant(s) named above:
PRODUCT USE
14Plaintiff/Decedent used the following GLP-1 RA Product(s) for which claims are being asserted in this case (check all that apply):
_____ Ozempic (semaglutide) _____ Wegovy (semaglutide) _____ Rybelsus (oral semaglutide) _____ Victoza (liraglutide) _____ Saxenda (liraglutide) _____ Trulicity (dulaglutide) _____ Mounjaro (tirzepatide) _____ Zepbound (tirzepatide) _____ Other(s) (specify): ____________________________________________
15To the best of Plaintiff(s)’ knowledge, Plaintiff/Decedent used GLP-1 RA Product(s) during the following approximate date range(s) (month(s) and year(s)) (if multiple products, specify date range(s) for each product):
Approx. August 2024 - November 2024
