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Form To Be Used By Prisoner In Filing Complaint Under Civil Rights Act Form. This is a Iowa form and can be use in USDC Northern Federal.
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Tags: Form To Be Used By Prisoner In Filing Complaint Under Civil Rights Act, Iowa Federal, USDC Northern
INSTRUCTIONS
You should use this packet if:
(1)
(2)
(3)
(4)
You are a prisoner; and
You believe your federal constitutional rights have been violated;
and
You wish to file a complaint under 42 U.S.C. § 1983 in the United
States District Court for the Northern District of Iowa; and
You do not have a licensed attorney to help you with your complaint.
This packet contains:
(1)
(2)
(3)
(4)
This 2-page sheet of INSTRUCTIONS;
Notice to Prisoners;
Form A (§ 1983 complaint form); and
Form B (Request to Proceed In Forma Pauperis and declaration).
§ 1983 or Habeas Corpus?
Sometimes prisoners do not know whether they should file a § 1983 action
or a habeas corpus action. Both § 1983 and the writ of habeas corpus can
help persons who have been deprived of federal constitutional rights.
However, if you will be asking the court for any kind of release from
custody, or if you will be asking the court to restore good and honor time
that was taken from you, you should file a habeas corpus action. (The
court cannot do those things for you in a § 1983 action.) In a habeas
corpus action, you must ask the state courts to help you before you ask for
the federal court’s help. This is not required for a § 1983 action.
DO NOT USE THE FORMS IN THIS PACKET TO APPLY FOR A WRIT OF HABEAS CORPUS.
A separate form is available for that purpose. The Clerk of Court can send
you a copy upon request.
The Correct Court and the Correct Defendants
Your complaint can be filed in the United States District Court for the
Northern District of Iowa only if one or more of the defendants is located
in this district, or if the facts of your complaint took place in this
district.
A defendant in a § 1983 action must be a person who acted “under color of”
state law.
This generally means that the person is either a state
official, a state employee, or someone else who acted for the state or
under some power given to him by the state.
(This is not a complete
statement of the law on this subject, but is intended only as guidance.)
In order for the warden or some other supervisory official to be a proper
defendant, you must have some proof that such person either: (1) personally
did some act that harmed you, or (2) harmed you by personally failing to
do something he should have done, or (3) authorized (in words or otherwise)
someone else’s conduct which harmed you, or (4) was aware of someone else’s
conduct which harmed you, and acquiesced in (went along with) that conduct
in some way.
It is important that you give the correct name and work address, if known,
of each person you name as a defendant, so that each of those persons can
be notified of your complaint.
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Filling Out the Forms
Your forms may be filled out by hand or by typewriter. If handwriting is
used, it must be clear and readable. If printing would be easier for the
court to read, please print.
Every question on the forms should be
answered, even if your answer is “None,” “Don’t Know,” or “N/A” (not
applicable).
Your complaint will be most effective if you (1) state your claim briefly
and plainly, and (2) tell the court only about the claim or claims you truly
believe to be important. Stick to the FACTS (who, what, where, when, how).
THE COMPLAINT SHOULD NOT CONTAIN LEGAL ARGUMENTS OR CASE CITATIONS.
If you need more space to answer a question, you may use the back side of
the form or an extra blank page. However, if you keep your answers brief
and to the point, as recommended above, extra space should not be needed in
most cases.
You, the plaintiff, must personally sign the complaint, and if there is more
than one plaintiff, each of you must sign. If a person other than a named
plaintiff helped you with your complaint, that person must sign in the place
indicated under Part VII.
Additional Claims
If, in addition to your § 1983 claim, you have other claims against one or
more of the defendants, you may state those claims on a separate sheet of
paper which you attach to the complaint form. Write the heading ADDITIONAL
CLAIMS at the top of the sheet. If you happen to know the name or number
of a statute that you think applies to your additional claim, you may state
it. It is not necessary, however, that you do so. If you just state the
facts, the court will determine what federal or state laws, if any, apply.
The court will also determine whether any state law claims can be decided
in federal court.
Do NOT include any habeas corpus claims with this
complaint. Those claims should be filed separately on a special habeas
corpus form which the Clerk of Court can send you.
Other Instructions
There is a fee of $350.00 for filing your complaint. You will also be
required to pay the cost of notifying each defendant on your complaint. In
prisoner cases, this is usually done by certified mail, which costs
relatively little. If you feel you cannot pay the full filing fee and
service costs for this action, you should fill out Form B: APPLICATION TO
PROCEED IN FORMA PAUPERIS AND DECLARATION IN SUPPORT THEREOF. If there is
more than one plaintiff, each plaintiff must complete a separate Form B.
The completed form(s) must be signed and returned to the Clerk of Court with
your Form A Complaint.
Mail your Form A complaint to the address below. With your complaint you
must send either a money order for $350.00 or completed and signed Form B.
When all forms have been received, the Clerk of Court will assign them to
a judge.
Mailing address:
Clerk of Court
Federal Building & U.S. Courthouse
101 1st Street SE, Room 313
Cedar Rapids, IA 52401
NOTE: YOUR COMPLAINT WILL NOT BE CONSIDERED BY THE COURT UNLESS YOU HAVE
FOLLOWED THESE INSTRUCTIONS AND THOSE ON THE FORMS THEMSELVES.
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IMPORTANT NOTICE TO PRISONERS
FILING AN ACTION UNDER 42 U.S.C. § 1983
NOTICE:
On April 26, 1996, the Prison Litigation Reform Act of 1995
was signed into law. This Act substantially affects the filing of civil
rights actions by prisoners.
Aspects of the new Prisoner Litigation
Reform Act of which any prisoner filing a § 1983 action must be aware
include the following:
(A)
You must exhaust available administrative remedies, including
any grievance system, before filing an action challenging
prison conditions under 42 U.S.C. § 1983 or any other federal
law.
(B)
Regardless of your financial status, you are required to pay
the full $350.00 filing fee. If you cannot submit the fee in
full when you file your action, you may request to proceed in
forma pauperis.
In no event will a prisoner be prohibited
from bringing a civil action or appealing a civil or criminal
judgment for the reason that the prisoner has no assets and no
means by which to pay the initial partial filing fee.
(1)
A prisoner seeking to proceed in forma pauperis must
submit an affidavit that includes a statement of all
assets the prisoner possesses, and he/she must submit a
certified copy of his/her “inmate account” statement (or
institutional equivalent) for the six-month period
immediately preceding the filing of the action.
(2)
The court will assess and, when funds exist, collect, as
a partial payment of any court fees required by law, an
initial partial filing fee of twenty percent (20%) of the
greater of:
(a)
(b)
the average monthly deposits to your prison
account; or
the average monthly balance in your prison account
for the six-month period immediately preceding the
filing of the action.
(3)
After payment of the initial partial filing fee, you must
make monthly payments of twenty percent (20%) of the
preceding month’s income credited to your prison account.
(The correctional facility charged with your custody will
forward payments from your prison account to the clerk of
the court each time the amount in the account exceeds
$10.00 until the filing fee is paid.)
(4)
Irrespective of any filing fee, or any portion thereof,
that may have been paid, the court must dismiss the case
at any time if the court determines that:
(a)
(b)
the allegation of poverty is untrue: or
the action or appeal:
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(i) is frivolous or
(ii) fails to state
be granted; or
(iii) seeks monetary
is immune from
malicious;
a claim upon which relief may
relief against a defendant who
such relief.
However, you are still responsible for paying any remaining
portion of the filing fee that is unpaid. (A further note:
the filing fee debt is not dischargeable in a bankruptcy
proceeding.)
(C)
If you have, on three or more occasions, while incarcerated or
detained in any facility, brought an action or appeal in a
court of the United States that was dismissed on the grounds
that it is frivolous, malicious, or fails to state a claim
upon which relief may be granted, YOU ARE PROHIBITED FROM
FILING A CIVIL RIGHTS ACTION IN FORMA PAUPERIS unless you are
under imminent danger of serious physical injury. If you do
not proceed in forma pauperis, (if you prepay the full $350.00
filing fee), you may file a new civil action or appeal, even
if you have three or more of these dismissals.
(D)
When proceeding in forma pauperis, a complaint in a civil
action in which a prisoner seeks redress from a governmental
entity or officer or employee of a governmental entity is
subject to judicial review.
On review, the court shall
identify arguable claims or dismiss the complaint, or any
portion of the complaint, if the complaint:
(1)
(2)
(E)
is frivolous, malicious, or fails to state a claim upon
which relief may be granted; or
seeks monetary relief from a defendant who is immune from
such relief.
In the event a monetary (money) judgment is awarded to a
prisoner as a result of a civil action against a jail, prison
or correctional facility or against any official or agent
thereof, the monetary award shall be paid directly to satisfy
any outstanding restitution orders pending against the
prisoner. Further, where the court has granted appointment of
counsel in the prisoner’s action, a portion of the judgment
(not to exceed twenty-five percent (25%)) will be applied to
satisfy the award of attorney’s fees against the defendant.
In addition, prior to any monetary award, notice of the
monetary award will be given to your crime victim(s), if any,
in the event they wish to file a claim against the award.
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FORM A:
FORM TO BE USED BY A PRISONER WHEN FILING A COMPLAINT UNDER
THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983
IN THE UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF IOWA
__________________________________:
__________________________________:
__________________________________:
__________________________________:
__________________________________:
(Enter above the full name of the
plaintiff or plaintiffs in this
action.)
vs.
COMPLAINT
__________________________________:
__________________________________:
__________________________________:
__________________________________:
__________________________________:
(Enter above the full name of the
defendant or defendants in this
action, if known.)
(NOTE: If there is more than one plaintiff, a separate sheet should be
attached giving the information in parts I and II below for each
plaintiff, by name.)
I.
Previous Lawsuits
A.
Have you begun other lawsuits in state or federal court
dealing with the same facts involved in this action or
otherwise relating to your imprisonment? YES ( ) NO (
)
B.
If your answer to A is YES, please answer the questions below.
(If there is more than one lawsuit, describe the additional
lawsuits on another piece of paper, using the same outline.)
1.
Parties to previous lawsuit:
Plaintiffs
______________________________________
________________________________________
Defendants
______________________________________
________________________________________
2.
Court (If federal court, name the district; if state
court, name the county.) _______________________________
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3.
Docket Number _________________________________________
4.
Name of judge to whom case was assigned _________________
________________________________________________________
5.
Disposition, if known (For example: Was the case
dismissed? Was it appealed? Is it still pending?)
_______________________________________________________
6.
7.
II.
Approximate date of filing lawsuit _____________________
Approximate date of disposition _______________________
Place of Present Confinement ______________________________________
A.
Is there a prisoner grievance procedure in this institution?
YES (
)
NO (
)
B.
Did you present the facts relating to your complaint in the
state prisoner grievance procedure? YES (
)
NO (
)
C.
If your answer is YES,
1.
What steps did you take? ________________________________
_______________________________________________________
________________________________________________________
2.
What was the result? ___________________________________
_______________________________________________________
________________________________________________________
D.
If your answer is NO, explain why not _______________________
_____________________________________________________________
E.
If there is no prisoner grievance procedure in
institution, did you complain to prison authorities?
YES (
)
NO (
)
the
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F.
If your answer is YES,
1.
What steps did you take? _______________________________
_______________________________________________________
_______________________________________________________
2.
What was the result? __________________________________
_______________________________________________________
_______________________________________________________
III. Parties
In item A below, place your name in the first blank and place your
present address in the second blank. Do the same for additional
plaintiffs, if any.
A.
Name of Plaintiff ____________________________________________
Address _______________________________________________________
B.
Additional Plaintiffs ________________________________________
____________________________________________________________
_____________________________________________________________
In item C below, place the full name of the defendant in
first blank, his official position in the second blank,
his place of employment in the third blank. Use item D
the names, positions, and places of employment of
additional defendants.
C.
the
and
for
any
Defendant ____________________________________ is employed as
____________________________ at _____________________________.
D.
Additional Defendant(s) is/are employed as ___________________
___________________________ at _______________________________
____________________________________________________________
_____________________________________________________________.
IV.
Jurisdiction
This complaint is brought pursuant to 42 U.S.C. § 1983, and
jurisdiction is based on 28 U.S.C. § 1343(a)(3).
Plaintiff(s)
allege(s) that the defendant(s) acted under color of state law with
regard to the facts stated in Part V of this complaint.
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V.
Statement of Claim
(State here as briefly as possible the FACTS of your case. You MUST
state exactly what each defendant personally did, or failed to do,
which resulted in harm to you.
Include also the names of other
persons involved (for example, other inmates) and state the date and
place of all events. Attach an extra sheet if necessary, and write
the heading PART V CONTINUED at the top of the sheet. Keep to the
facts. Do not give any legal arguments or cite any cases.)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
__________________________________________________________________
VI.
Relief
(State briefly exactly what you want the court to do for you. Make
no legal arguments. Cite no cases or statutes.)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
__________________________________________________________________
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VII. Statement Regarding Assistance in Preparing This Complaint
A.
Did any person other than a named plaintiff in this action
assist you in preparing this complaint? YES (
)
NO (
)
B.
If your answer is YES, name the person who assisted you.
____________________________________________________________
C.
Signature of person who helped prepare complaint.
_________________
(Date)
_______________________________________
(Signature)
VIII. Signature(s) of Plaintiff(s)
Signed this _______ day of ___________________________, 20_____.
_____________________________________________
(Signature)
Signatures of additional plaintiffs, if any:
_____________________________________________
____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
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IN THE UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF IOWA
____________________ DIVISION
FORM B:
_________________________________,
Plaintiff,
Civil No. ___________________
vs.
_________________________________
APPLICATION TO PROCEED
_________________________________
IN FORMA PAUPERIS
________________________________,
IN CIVIL RIGHTS ACTION
Defendants.
I, ____________________________________, declare that I am the
plaintiff in the above-entitled proceeding; that, in support of my
request to proceed without being required to prepay the full $350.00
filing fee, I state that because of my poverty, I am unable to prepay the
filing fee for this action; that I believe I am entitled to relief.
In further support of this application, I answer the following
questions:
1.
Where are you imprisoned? ____________________________________
2.
When did you begin your imprisonment there? __________________
3.
When do you expect to be released? ___________________________
4.
Are you presently receiving an allowance or wages from the
prison or jail? YES (
)
NO (
) If the answer is YES,
state the amount of your allowance or wages per month.
______________________________________________________
5.
Have you received within the past twelve (12) months any money
from a business, profession or other type of self-employment,
or in the form of rent payments, interest, dividends,
retirement or annuity, gifts, inheritances, court award or
settlement, or other sources? YES (
)
NO (
) If YES,
give the amount received and identify the source(s):
____________________________________________________________
____________________________________________________________
____________________________________________________________
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6.
What is the current balance in your prison account? $_________
7.
Do you own cash, or do you have money in a checking or savings
account, other than a prison account? YES (
)
NO (
)
If YES, state the current balance: $____________
7.
Do you own any real estate, stocks, bonds, notes, vehicles, or
other valuable property (you need not mention ordinary
household and cell furnishings, such a radios, TV sets,
stereo, books, etc., and personal clothing)? YES(
) NO(
)
If YES, describe the property and state its approximate value:
____________________________________________________________
_____________________________________________________________
I hereby authorize officials of the institution where I am
incarcerated to release my financial records to the court.
My
identification number at this institution is: _____________________.
I further authorize the agency holding me in custody to
disburse funds in an amount not to exceed $350.00 from my inmate
account to the Clerk of the United States District Court for the
Northern District of Iowa, for the purpose of paying the initial
partial filing fee and subsequent installment payments in this case.
I declare under penalty of perjury that I have read the foregoing
and it is true, complete and correct.
Signed this _________ day of ____________________, 20_____.
______________________________
(Signature of Plaintiff)
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CERTIFICATION OF INMATE ACCOUNT AND ASSETS
I certify that the applicant, _________________________________,
I.D.
#
_______________________________________
has
the
sum
of
$____________________
on
account
to
his/her
credit
at
the
__________________________________________________ institution where
he/she is confined.
I further certify that the applicant likewise has the following
securities to his/her credit according to the records of said
institution:
______________________________________________________________________
____________________________________________________________.
I further certify that, during the last six months, the applicant’s
average inmate account balance was $_______________, and the past sixmonth average monthly deposit amount to the inmate account is
$___________________.
Based on the above inmate account balance:
(Check the appropriate response)
_____
The applicant has sufficient funds in his/her account to pay
the $350.00 filing fee; OR
_____
The applicant has insufficient funds in his/her account to pay
the $350.00 filing fee at this time. I calculate that twenty
percent (20%) of the greater of:
(a)
the average monthly deposits to his/her prison account;
or
(b)
the average monthly balance in his/her prison account
for the six-month period immediately preceding the
filing of this action
is $______________________, for the purpose of an initial
partial filing fee.
After payment of the initial partial
filing fee, this office will forward twenty percent (20%) of
the applicant’s previous month’s income as monthly payments
from his/her prison account to the clerk of the court each
time the amount in the amount exceeds $10.00, until the
$350.00 filing fee is paid in full.
Signed this _________ day of ______________________, 20________.
___________________________________
Authorized Officer of Institution
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