Form To Be Used In Filing Complaint Under Civil Rights Act 42 USC 1983 (Prisoner Complaint Form)

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Revised 05/01 WDNY Index No. Calendar No. UNITED STATES DISTRICT COURT : WESTERN DISTRICT OF NEWJUDICIAL SUBPOENA YORK Plaintiff(s) -against- : HOW TO FILE YOUR CIVIL RIGHTS CASE UNDER 42 U.S.C. § 1983 (Instructions for Prisoner's Complaint) : : The Western District’s web site at www.nywd.uscourts.gov contains copies of many of the Court’s forms and other useful information. Defendant(s) : ...................................................... IMPORTANT: This packet includes the civil rights complaint forms and additional materials you have requested. Although you are not required to submit your complaint on the complaint form, you must provide all the information requested on that form. If you choose not to use the official form, be sure that you provide all the THE PEOPLE OF THE STATE OF NEW form information that is requested on the official YORKand that you enclose the proper number of correctly filled out supporting documents. If your papers are not properly completed, your papers will be returned to you for TO correction of any deficiencies. Based on the mandates of 28 U.S.C. §§ 1915 and 1915A, the Court will conduct an initial review of any complaint of a prisoner who either is seeking in forma pauperis status under § 1915 or who is suing a governmental entity, GREETINGS: officer or employee. Because until this review is conducted, it is not certain that all of your claims against all of your defendants will remain when the that all directs service of your complaint, the Courteach of you attend before WE COMMAND YOU, Court business and excuses being laid aside, you and will not send you U.S. Marshal forms and summons forms at this time. , the Honorable at the Court located at County of in room , on the , Court ,may dismissed the claims in whole oratin part and it at o'clock in the noon, and any recessed Additionally, based on its review of day complaint, the 20 the of or adjourned date, to file an amended complaint. Therefore, you should wait of the may also require you to testify and give evidence as a witness in this action on the partuntil the initial review of the complaint is completed and you know which complaint will be going forward and how many copies of the complaint will be needed before you make more than one set of copies of your papers. (You should keep for your own records one copy of the papers you send to the Court.)punishable as a contempt of court and will make you liable to Your failure to comply with this subpoena is the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a You will be of your failure to comply. of U.S. Marshal and summons forms when the Court directs service of the result sent the correct number complaint. At that time, you should complete the forms and return them to the Court, together with the appropriate number of exactWitness,of your complaint, so that the U.S. Marshal may serve your summons and of the copies Honorable , one of the Justices complaint on the defendants. in Court County, day of , 20 Your new action will be accepted for filing if your papers include the following: (1) one completed and signed complaint form, (Attorney must sign above and type name below) (2) one signed Authorization, together with a completed and signed application to proceed in forma Attorney(s) and pauperis (in which the prison certification section has been filled in for signed by the appropriate person in your correctional facility), and (3) one completed and signed Civil Cover Sheet. Office and P.O. Address Follow the instructions below for completing each form and gathering the documents together for filing. Note that these instructions also deal with other issues which will arise in your case. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. I. COMPLAINT FORM 1. JUDICIAL You should also Plaintiff(s) To start an action, you must file a complaint which contains an original signature. SUBPOENA keep an -againstexact copy of the complaint for your records. : : After the Court has determined that your case is going: forward and against whom it is going forward, you will be required to provide an exact copy of the complaint which is going forward (note that it : may be an amended complaint at that point) for each defendant against whom the case is proceeding, and one extra copy. For example,Defendant(s)is going forward against two defendants, you must file if the case : . . . . . . . . the. .original .and. .three .copies . of . the. .complaint . (one original, plus a copy for each of the two .. ...... .. .... ..... .. .. ........ .... defendants plus one extra copy). All copies of the complaint must be identical to the original. Do not prepare these copies for the defendants until the Court advises you of the form of the complaint which is going forward and the number of copies which will be needed. THE PEOPLE OF THE STATE OF NEW YORK 2. 3. TO Your complaint must be legibly handwritten or typewritten, in blue or black ink if possible, preferably on the enclosed forms. If you need additional space to answer a question, you may attach additional pages. However, additional pages should be used only if absolutely necessary; your complaint should be specific but as brief GREETINGS: as possible; you should not include legal argument or case citations in your complaint allegations . Just tell your story simply and clearly. Please refer to Rules 8(a)(2) and 10(b) of the Federal WE COMMAND for the requirements and excuses being laid aside, you and your complaint. before Rules of Civil Procedure YOU, that all businessgoverning the format and content of each of you attend Failure the Honorable Court to comply with these requirements may lead toat the a Court order rejecting your complaint until it does comply. , located at County of inSection 1: Caption the This section requires you to list, at room , on — day of , 20 o'clock in the noon, and at plaintiff and your name and prisoner number as the any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the the names of all of the defendants. Do not use abbreviations such as "etc." or "et al." Also, note that only those defendants whose names are listed in this Section (or in the caption if you do not use the official forms) will be considered by the Court as defendants. 4. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued that a maximum penalty of action pursuant to the Civil Rightsa Section 2: Jurisdiction — This section states for you have brought this $50 and all damages sustained as result of your U.S.C.to comply. Statute, 42 failure § 1983, and that the Court has jurisdiction over your claims under 28 U.S.C. §§ 1331, 1343(3) and (4), and 2201. You may add additional jurisdictional statutes, if appropriate. 5. Witness, Honorable , one of the Justices of the Section to This Court in 3: Parties County, Action — This section 20 day of , requires you to identify the parties to the lawsuit. (You should set out in Section 1: Caption only the parties’ names and perhaps their titles (such as Dr. or Sergeant)). In Section 3: Parties, you must provide the parties' official positions and addresses, and you may provide any other information which may assist in identifying or locating the parties. If you are not using (Attorney must sign above and type name below) the official forms, your complaint must have a section which identifies and locates the parties in this way. 6. Section 4: Previous Lawsuits — This section requires Attorney(s) for detailed, accurate and thorough you to provide information about all previous lawsuits you have filed. If you cannot provide all of the details requested, you must provide as much information as you can. Deliberate misrepresentation or omission of information is perjury and is punishable by law. 7. Section 5: Statement of Claim — This section, which is divided into separate sub-sections for each claim, requires you to tell the Court when each alleged constitutional violation occurred, which defendant(s) did the violation and specifically what each of the defendant(s) did to you. You must provide specific facts Office and P.O. Address 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar regarding each claim; these facts should demonstrate to the Court how your No. rights were violated and civil by whom they were violated. : JUDICIAL SUBPOENA Plaintiff(s) -againstYou must give facts only – THIS MEANS JUST TELL THE COURT WHAT HAPPENED TO YOU. : Tell your story without legal jargon. Please refer again to Rule 8(a)(2) and 10(b) of the Federal Rules of Civil Procedure regarding how to present your claim. Your : complaint must not contain legal arguments or case citations. : Your must also state the constitutional Defendant(s)each claim (such as the First Amendment, Eighth basis for : . .Amendment, .Due .Process. Clause. or .Equal. Protection. Clause), and describe what relief you are seeking for .......... ... ...... ..... .. .... ........ ....... each claim. In addition, note that you may be required to have exhausted your administrative remedies regarding each claim for which there is an administrative process and remedy. See 42 U.S.C. § 1997e(a). The legal interpretation of this requirement is still evolving. THE PEOPLE OF THE STATE OF NEW YORK 8. If TO you wish a jury trial, check "yes" on the complaint form (and check "yes" in the JURY DEMAND box on the Civil Cover Sheet.) If you do not use the official forms, you must state in the body of your complaint that you demand a jury trial. 9. Sign the complaint before a notary public, if one is available to you. If not, your signature at the end of your GREETINGS: complaint under penalty of perjury is adequate. 10. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the Honorable at the Court Amended Complaints — An amended complaint completely replaces your original complaint and must , located at County of include all of the necessary allegations. You may file one amended complaint as of right at any therefore intime before an answer to the day of complaint, is served. You may also be instructed by the Court to file room , on the 20 , at o'clock in the noon, and at any recessed original or adjourned date, to testify and give evidence as a witness in this action on the part of the an amended complaint. If you wish to amend after an answer has been filed, you may do so either by obtaining permission of all other parties to the action or by bringing a motion asking the Court for permission to amend. Refer to Rule 15(a) of the Federal Rules of Civil Procedure for the requirements for amended complaints. comply with this subpoena is punishable as a contempt of court and will make you liable to Your failure to 11. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. — You may file a supplemental complaint only if you request permission Supplemental Complaints of the Court by motion with notice to the opposing parties. A supplemental complaint may only address Witness, Honorable events which have occurred since the time the original complaint was, one ofand Justices arethe some way filed the which of in related Refer Court in to the original allegations.day of to Rule 15(d) of the Federal Rules of Civil Procedure for the County, , 20 requirements for supplemental complaints. (Attorney must sign above and type name below) II. FILING FEES AND "POOR PERSON'S STATUS" 1. In order to file the completed complaint and other necessary papers, you must submit a $150.00 money Attorney(s) for order, certified check or official check made out to "Clerk, United States District Court". Do not send a personal check. (If your complaint is filed in person, you may pay in cash.) 2. If you are unable to pay the fee at the time of filing, you may apply for poor person's status. Because you Office and P.O. Address are a prisoner, this status does not relieve you of the obligation to pay the entire $150.00 filing fee, see 28 U.S.C. § 1915(b), but it will permit you to initiate your action without simultaneous payment of the filing fee, which will instead be taken out of your inmate account over time pursuant to statute. 3 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 3. Index No. : To request poor person's status, you must fill out the Application toCalendar No.Forma Pauperis and submit Proceed In one original to the Clerk of Court along with your complaint. :Be sure to get the prison certification section JUDICIAL SUBPOENA Plaintiff(s) completed by the appropriate prison officials before you file your papers; failure to do so will result in delay -againstin the initiation of your action. : : In addition, you must complete the enclosed Authorization Form and submit the original Authorization to the Clerk of the Court along with your Motion to Proceed In Forma Pauperis and Supporting Affidavit. The : Authorization permits the facility in which you are incarcerated to encumber an initial partial filing fee based upon your financial status for the past six Defendant(s) rest of the fee will be encumbered over time until the months; the : . .full .fee .has. been .paid. . (Please. .Note: . .The. full .fee .must . . . paid whether or not your action is dismissed or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . be goes forward; a dismissal does not cause the encumberance to be withdrawn.) III. 1. THE PEOPLE OF THE STATE OF NEW YORK CIVIL COVER SHEET Fill TO out the "Civil Cover Sheet" form according to these instructions: Fill in your name and prisoner number (if applicable) in the "Plaintiff" section; 2. Fill in all of GREETINGS:the defendants' names in the "Defendants" section (use a second sheet if necessary); 3. WE COMMAND YOU, and of the county excuses being defendants in the appropriate "b" sections Fill in the name of your county that all business and of one of yourlaid aside, you and each of you attend before , the Honorable and Defendant; at the Court under Plaintiff located at County of inIn the "Plaintiff's on the room , Attorney" section, write "Pro 20 and then add your name, your prisonerany recessed day of , Se" , at o'clock in the noon, and at number (if orapplicable),date, to testify and give evidence as a witness in this action on the part of the adjourned and your address; 4. 5. 6. 7. 8. Leave the "Defendant's Attorney" section blank; Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to In the"Basis of Jurisdiction" subpoena was issued for Questions"; the party on whose behalf thissection, check "3, Federal a maximum penalty of $50 and all damages sustained as a result of your failure to comply. In the"Cause of Action" section, write "42 U.S.C. § 1983, Civil Rights Action"; Witness, Honorable , one of the Justices of the In the Court in"Nature of Suit" section, check box 550: "Prisoner Petitions, Civil Rights"; County, day of , 20 9. In the"Origin" section, check box 1: "Original Proceeding"; 10. Leave the"Citizenship of Principal Parties" section blank; 11. In the"Requested in Complaint" section, write in the amount of money you are suing for and check the Attorney(s) for appropriate box after "jury demand" (see discussion in Part I(8) above); 12. In the "Related Cases" section, list all your previously-filed cases, together with their docket numbers, the courts in which they were venued, the approximate dates they were filed and their dispositions, using a Office and P.O. Address separate sheet if necessary; and 13. On the last line, date the form and sign your name, followed by "Pro Se" and your prisoner number (if Telephone No.: applicable). 4 (Attorney must sign above and type name below) Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : IV. : FILING YOUR COMPLAINT Index No. Calendar No. : JUDICIAL SUBPOENA Once your papers are complete (meaning that Plaintiff(s) a complaint with an original signature, a completed you have application to proceed in forma -against- and a signed Authorization : pauperis form, and a completed civil cover sheet), send them to the Clerk's Office at one of the addresses listed below. Upon receipt, your complaint will be assigned a : docket number and a judge. Notice of this will be sent to you. : If you are suing a government official (see 28 U.S.C. § 1915A) or if you have applied for permission to proceed in forma pauperis (see 28 U.S.C. § 1915), you may not cause copies of your papers to be served on Defendant(s) : any named.defendant, . either. by .yourself .or. at .your .request .by. the. United States Marshals Service, until the Court ..... ......... .... .. ...... . .. ... ...... . .. .. directs service of the complaint (even if you have paid the entire $150.00 filing fee at the time you filed the complaint). THE PEOPLE OF THE STATE OF NEW YORK V. SERVICE OF FORMS TO If you apply for permission to proceed in forma pauperis and the Court grants your request, the United States Marshal will, at the Court's direction, serve the summons and complaint upon each defendant. When the Court grants GREETINGS: your application to proceed in forma pauperis and directs service by the U.S. Marshal, you will receive the correct number of Summons and U.S. Marshal Process Receipt and Return forms together with instructions for WE completing them. COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at proceed in forma pauperis, you may ask the Court for an order County of If you do not apply for or receive permission to in service of the ,complaint by the U.S. Marshals at your expense (the present charge for this any recessed on the day of , 20 , at o'clock in the noon, and at is $8.00 per directingroom or adjourned date, to testify and give evidence as a witness in this action on the part of the complaint). Note that 28 U.S.C. §§ 1915 and 1915A impose certain service limitations on prisoners even if they have paid the filing fee. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (These limitations are referenced in Section IV above.) the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to service No matter which method of comply. you choose, Rule 4(m) of the Federal Rules of Civil Procedure requires that service of the summons and complaint must be made within 120 days after the filing of the complaint. Witness, this deadline may result in dismissal of your action. (Inthe Justices of the , one of certain cases, where delay in Failure to comply with Honorable service is related to action County, the Court – such as directing you to amend your complaint before it directs taken by Court in day of , 20 service by the U.S. Marshal – this time may not start running until service is actually directed.) If the Marshal fails to complete service upon the first attempt, (Attorney must sign above and type require the Marshal it is your responsibility to name below) to try to serve again, or to move the Court for an order directing the Marshal to make a second attempt. Attorney(s) for VI. GENERAL INFORMATION 1. Your complaint can be filed in this Court only if one or more of the named defendants is located within the Western District of New York, or if the action occurred in the District pursuant to 28 U.S.C. § 1391. Office and P.O. Address Further, it may be necessary for you to file a separate complaint for each claim that you have unless they are all related to the same incident or issue. 2. Telephone No.: After issue is joined (which means that the defendant has filed an answer or a motion to dismiss), you must Facsimile No.: first send a copy of every legal paper to the defendant's attorney before you send the original to the E-Mail Address: Court to be filed in your case. Mobile Tel. No.: 5 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : This means that each paper you wish to file in the Court must first Calendar No. the defendant's counsel (by be served on mailing it to him). Then attach to the original that you want to file in the Court, as a last page, a signed : JUDICIAL This statement Plaintiff(s) statement that you have sent a copy of your pleadings to the defendant's attorney. SUBPOENA is known -againstas the Affidavit/Affirmation of Service, and is evidence that you have served the papers on your opposition. : You may obtain a form for the Affidavit/Affirmation of Service from the Pro Se Staff Attorneys. : Failure to first send a copy to opposing counsel will result in your papers being refused for filing. : Note that the United States Marshal will serve only your complaint (and later, certain subpoenas) if you have Defendant(s) : . .been granted. poor .person. status. . .You .are. responsible. for. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . sending all subsequent papers to the defendants or their attorney(s) yourself. The District Court will not make copies for you nor will it send copies to the opposing party for you. If you are unable to make photocopies or carbon copies, you may submit identical handwritten copies. THE PEOPLE OF THE STATE OF NEW YORK 3. Requests for assigned counsel may be made pursuant to 28 U.S.C. § 1915(e)(1). The Court will make every TO effort to appoint counsel in civil rights cases filed by inmates, but generally only after the plaintiff's allegations have demonstrated some degree of merit to the Court, some need for such representation, and that you have already made some unsuccessful effort to locate an attorney to represent you. Denial of requests for GREETINGS: appointment of counsel before such time shall be without prejudice to renewal after the case has progressed closer to trial. You may obtain a form for requesting counsel from the Pro Se Staff Attorneys. 4. 5. 6. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the Honorablenotify the Clerk's Office and all defendants (or their attorneys) immediately of any address , at the Court You must located at County of Failure to do so may result in dismissal of your action pursuant to Local Rule of Civil changes. inProcedure 5.3(d). the room , on day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the The Clerk of Court will not file your complaint unless it conforms to these instructions pursuant to Local Rules of Civil Procedure 5.2 and 5.3. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose than one plaintiff, each and every a maximum penalty of $50 and all damages sustained as a If there is more behalf this subpoena was issued for plaintiff must sign the complaint individually and must result ofseparately for permission to proceed in forma pauperis, if applicable. After the complaint has been apply your failure to comply. filed, one plaintiff may submit a document to be filed on behalf of all the plaintiffs only if the other Witness, Honorable , one of submit documents on all plaintiffs have signed a statement giving that plaintiff the authority to the Justices of the plaintiffs’ behalf. Otherwise, each plaintiff must ,sign every document submitted to the Court. Court in County, day of 20 (Attorney must sign above and type name below) VII. MAILING INSTRUCTIONS Finally, mail or bring all of the papers to one of the following addresses: United States District Court Clerk 2120 U.S. Courthouse 100 State Street Rochester, New York 14614-1387 (585) 263-6263 Attorney(s) for United States District Court Clerk 304 U.S. Courthouse 68 Court Street Buffalo, New York 14202-3498 Office and P.O. Address (716) 551-4211 or (716) 551-5759 If you have general questions about procedures, you may contact the Pro Se Staff Attorneys at one of the above Telephone No.: addresses for information. Note: The Pro Se Staff Attorneys can only provide technical and procedural information Facsimile No.: and some forms such as for filing motions and the affirmation/affidavit of service; they cannot assist you with the E-Mail Address: substantive law governing your lawsuit or give you legal advice. Mobile Tel. No.: 6 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. UNITED STATES DISTRICT COURT : JUDICIAL SUBPOENA WESTERN DISTRICT OF NEW YORK Plaintiff(s) Revised 05/01 WDNY -against- : FORM TO BE USED IN FILING A COMPLAINT UNDER THE CIVIL RIGHTS ACT, :42 U.S.C. § 1983 (Prisoner Complaint Form) : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.. .CAPTION .OF .ACTION . ........ .. ...... Full Name And Prisoner Number of Plaintiff: NOTE: If more than one plaintiff files this action and seeks in forma pauperis status, each plaintiff must submit an in forma pauperis application and a signed Authorization or the only plaintiff to be considered will be the plaintiff who filed an application and Authorization. THE PEOPLE OF THE STATE OF NEW YORK A. 1. TO 2. -VSB. GREETINGS: Full Name(s) of Defendant(s) NOTE: Pursuant to Fed.R.Civ.P. 10(a), the names of all parties must appear in the caption. The court may not consider a claim against anyone not identified in this section as a defendant. If you have more than six defendants, WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before you may continue this section on another sheet of paper if you indicate below that you have done so . 1. 2. 3. , the Honorable at the 4. Court located at County of in room , on the day of , 20 5. at , o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness6. this action on the part of the in Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 2. STATEMENT OF JURISDICTION the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. This is a civil action seeking relief and/or damages to defend and protec t the rights guaranteed by the Constitution of the United States. This actionHonorable pursuant to 42 U.S.C. § 1983. The Court has ,jurisdiction Justices of the pursuant to Witness, is brought one of the over the action 28 U.S.C. §§ in 1331, 1343(3) and (4), and 2201. of Court County, day , 20 3. PARTIES TO THIS ACTION (Attorney must sign above and type name below) PLAINTIFF’S INFORMATION NOTE: To list additional plaintiffs, use this format on another sheet of paper. Name and Prisoner Number of Plaintiff: Present Place of Confinement & Address: Name and Prisoner Number of Plaintiff: Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Present Place of Confinement & Address: Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : DEFENDANT’S INFORMATION NOTE: To provide information about more defendants than there is room for here, use this : format on another sheet of paper. : Name of Defendant: Defendant(s) : ...................................................... (If applicable) Official Position of Defendant: (If applicable) Defendant is Sued in _______Individual and/or _______Official Capacity Address of Defendant: THE PEOPLE OF THE STATE OF NEW YORK TO Name of Defendant: (If applicable) Official Position of Defendant: GREETINGS: (If applicable) Defendant is Sued in _______Individual and/or _______Official Capacity Address of Defendant: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned Name of Defendant: date, to testify and give evidence as a witness in this action on the part of the (If applicable) Official Position of Defendant: (If applicable) Defendant is Sued in _______Individual and/or _______Official Capacity Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Address ofparty on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the Defendant: result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 4. PREVIOUS LAWSUITS IN STATE AND FEDERAL COURT A. (Attorney must sign above and type name below) Have you begun any other lawsuits in state or federal court dealing with the same facts involved in this action? Yes No If Yes, complete the next section. NOTE: If you have brought moreAttorney(s) for dealing with the same facts as this than one lawsuit action, use this format to describe the other action(s) on another sheet of paper. Name(s) of the parties to this other lawsuit: 1. Plaintiff(s): Office and P.O. Address Defendant(s): 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 2. Index No. Calendar No. Court (if federal court, name the district; if state court, name the county): : Plaintiff(s) 3. Docket or Index Number: -against- : 4. Name of Judge to whom case was assigned: : 5. The approximate date the action was filed: 6. JUDICIAL SUBPOENA What was the disposition of the case? : Defendant(s) : . . . . . . . . Is. it .still.pending?. .Yes. . . . . . No . . . . . . . . . . . . . . . . . . . . . . . .. ...... .. .. If not, give the approximate date it was resolved. Disposition (check the statements which apply): THE PEOPLE OF THE STATE OF NEW YORK ____ Dismissed (check the box which indicates why it was dismissed): TO ____ ____ GREETINGS: By court sua sponte as frivolous, malicious or for failing to state a claim upon which relief can be granted; By court for failure to exhaust administrative remedies; ____ By court for failure to prosecute, pay filing fee or otherwise respond to a court order; WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable ____ By court due to your voluntary withdrawal of claim; at the Court located at County of____ Judgment upon motion or after trial entered for in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date,____ plaintiff give evidence as a witness in this action on the part of the to testify and ____ defendant. B. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Have you begun any other lawsuits in federal court which relate to your imprisonment? the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure toNo comply. Yes If Yes, complete the next section. NOTE: If you have brought more than one other lawsuit dealing with your imprisonment, Witness, Honorable , one of the Justices of the use this same format to describe the other action(s) on another sheet of paper. Court in 1. County, day of , 20 Name(s) of the parties to this other lawsuit: Plaintiff(s): (Attorney must sign above and type name below) Defendant(s): Attorney(s) for 2. District Court: 3. Docket Number: 4. Name of District or Magistrate Judge to whom case was assigned: Office and P.O. Address 3 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : 5. What was the disposition of the case? : JUDICIAL SUBPOENA The approximate date the action was filed: 6. Calendar No. Plaintiff(s) Is it still pending? -against- No Yes : If not, give the approximate date it was resolved. : Disposition (check the statements which apply): : ____ Dismissed (check the box which indicates why it was dismissed): Defendant(s) : . . . . . . . . . . . . . . .____. . . By . court. .sua. sponte. as. . . . . . . . . . . . . . ... . . . . . . . . . . . . . . frivolous, malicious or for failing to state a claim upon which relief can be granted; ____ By court for failure to exhaust administrative remedies; THE PEOPLE OF THE STATE OFfor failure to prosecute, pay filing fee or otherwise respond to a court ____ By court NEW YORK order; TO ____ By court due to your voluntary withdrawal of claim; ____ Judgment upon motion or after trial entered for GREETINGS: ____ plaintiff ____ defendant. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in CLAIM on the part of the 5. STATEMENT OF this action For your information, the following is a list of some of the most frequently raised grounds for relief in proceedings under 42 U.S.C. § 1983. (This list does not include all possible claims.) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to • Religion • Access to issued for • Search & Seizure the party on whose behalf this subpoena was the Courts a maximum penalty of $50 and all damages sustained as a result of your failure to comply. • False Arrest • Free Speech • Malicious Prosecution • Due Process • Equal Protection Witness, Honorable Court in County, • Excessive Force • Failure to Protect • Denial of Medical Treatment • Right to Counsel the Justices of the , one of day of , 20 Please note that it is not enough to just list the ground(s) for your action. You must include a statement of the facts which you believe support each of your claims. In other words, tell the story of what happened to you but do not use legal jargon. (Attorney must sign above and type name below) Fed.R.Civ.P. 8(a) states that a pleading must contain "a short and plain statement of the claim showing that the pleader is entitled to relief." "The function of pleadings under the Federal Rules is to give fair notice of the claim asserted. Fair notice is that which will enable the adverse party to answer and prepare for trial, allow the application of res judicata, and identify the nature of the case so it may be assigned the proper form of trial." Simmons v. Abruzzo, 49 F.3d 83, 86 (2d Cir. 1995). Attorney(s) for Fed.R.Civ.P. 10(b) states that “[a]ll averments of claim ... shall be made in numbered paragraphs, the contents of each of which shall be limited as far a practicable to a single set of circumstances.” Office and P.O. Address 4 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. Exhaustion of Administrative Remedies Plaintiff(s) : JUDICIAL SUBPOENA Note that according to 42 U.S.C. § 1997e(a), “[n]o action shall be brought with respect to prison conditions under section -against1983 of this title, or any other Federal law, by a prison er confined in any : prison, or other correctional facility until such jail, administrative remedies as are available are exhausted.” : You must provide information about the extent of your efforts to grieve, appeal, or otherwise exhaust your administrative : remedies, and you must attach copies of any decisions or other documents which indicate that you have exhausted your remedies for each claim you assert in this action. Defendant(s) : ...................................................... A. FIRST CLAIM: On (date of the incident) , THE PEOPLE OF THE STATE OF NEW YORK defendant (give the name and position held of each defendant involved in this incident) TO did the following to me (briefly state what each defendant named above did): GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a The constitutional basis for this comply. result of your failure to claim under 42 U.S.C. § 1983 is: Witness, Honorable Court in County, , one of the Justices of the The relief I am seeking for this claim is (briefly state the relief sought): day of , 20 (Attorney must sign above and type name below) Exhaustion of Your Administrative Remedies for this Claim: Did you grieve or appeal this claim? ______ Yes ______ No If yes, what was the result? Attorney(s) for Did you appeal that decision? ______ Yes ______ No If yes, what was the result? Attach copies of any documents that indicate that Office and P.O. Address you have exhausted this claim. 5 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. If you did not exhaust your administrative remedies, state why you did not do so: Plaintiff(s) -against- : JUDICIAL SUBPOENA : : A. SECOND CLAIM: On (date of the incident) , : defendant (give the name and position held of each defendant involved in this incident) Defendant(s) : ...................................................... did theTHE PEOPLE OF THE state what each defendant named above did): following to me (briefly STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed The constitutional basis for this claim under 42 U.S.C. § 1983 is: or adjourned date, to testify and give evidence as a witness in this action on the part of the The relief I am seeking for this claim is (briefly state the relief sought): Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Exhaustion of Your Administrative Remedies for this Claim: Witness, Honorable Did you grieve or appeal this claim? ______day of Yes ______ No Court in County, Did you appeal that decision? ______ Yes ______ No , one of the Justices of the If20 what was the result? , yes, If yes, what was the result? (Attorney must sign above and type name below) Attach copies of any documents that indicate that you have exhausted this claim. Attorney(s) for If you did not exhaust your administrative remedies, state why you did not do so: Office and P.O. Address If you have additional claims, use the above format and set them out on additional sheets of paper. 6 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 6. RELIEF SOUGHT Index No. Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) Summarize the relief requested by you in each statement of claim above. -against- : : : Defendant(s) : ...................................................... Do you want a jury trial? Yes No I declare under penalty of perjury that the foregoing is true and correct. THE PEOPLE OF THE STATE OF NEW YORK Executed on TO (date) NOTE: Each plaintiff must sign this complaint and must also sign all subsequent papers filed with the Court. GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before of Plaintiff(s) , the Honorable at the Signature(s) Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 7 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com