UNITED STATES DISTRICT COURT002 DISTRICT OF OREGON002 DIVISION002 (Enter full name of plaintiff) Plaintiff, v. (Enter full name of ALL defendant(s)) Defendant(s). Civil Case No. (to be assigned by Clerk's Office) COMPLAINT FOR VIOLATION OF CIVIL RIGHTS (PRISONER COMPLAINT) Jury Trial Demanded Yes No I. PARTIES List your name, address, and telephone number below, and the same information for each defendant. Make sure that the defendant(s) listed below are identical to those contained in the caption of the complaint. Attach additional sheets of paper if necessary. Plaintiff Name: Street Address: City, State & Zip Code: Telephone No.: Complaint for Violation of Civil Rights (Prisoner Complaint) [Rev. 01/2018] 1 American LegalNet, Inc. www.FormsWorkFlow.com Defendant No. 1 Name: Street Address: City, State & Zip Code: Telephone No.: Defendant No. 2 Name: Street Address: City, State & Zip Code: Telephone No.: Defendant No. 3 Name: Street Address: City, State & Zip Code: Telephone No.: Defendant No. 4 Name: Street Address: City, State & Zip Code: 002Telephone No.:002 II. BASIS FOR JURISDICTION Under 42 U.S.C. 247 1983, you may sue state or local officials for the "deprivation of any rights, privileges, or immunities secured by the Constitution and [federal laws]." Under Bivens v. Six Unknown Agents of Federal Bureau of Narcotics, 403 U.S. 388 (1971), you may sue federal officials for the violation of certain constitutional rights. A. You are bringing suit against (check all that apply): Federal officials (a Bivens claim)002 State or local officials (a 247 1983 claim)002 Complaint for Violation of Civil Rights (Prisoner Complaint) [Rev. 01/2018] 2 American LegalNet, Inc. www.FormsWorkFlow.com B. What federal constitutional, statutory, or treaty right(s) is/are at issue? III. STATEMENT OF CLAIMS002 Claim I002 State here as briefly as possible the facts of your case. Describe how each defendant was involved, when the conduct occurred, and any injuries you have suffered as a result. It is not necessary to give any legal arguments or cite any cases or statutes. Claim II State here as briefly as possible the facts of your case. Describe how each defendant was involved, when the conduct occurred, and any injuries you have suffered as a result. It is not necessary to give any legal arguments or cite any cases or statutes. Complaint for Violation of Civil Rights (Prisoner Complaint) [Rev. 01/2018] 3 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Claim III State here as briefly as possible the facts of your case. Describe how each defendant was involved, when the conduct occurred, and any injuries you have suffered as a result. It is not necessary to give any legal arguments or cite any cases or statutes. (If you have additional claims, describe them on another piece of paper, using the same002 outline.)002 Complaint for Violation of Civil Rights (Prisoner Complaint) [Rev. 01/2018] 4 American LegalNet, Inc. www.FormsWorkFlow.com IV. EXHAUSTION OF ADMINISTRATIVE REMEDIES002 I have filed for administrative relief as to all claims in Section III and have concluded all administrative appeals available to me. Yes No V. RELIEF State briefly exactly what you want the court to do for you and the amount, if any, of monetary compensation you are seeking. Make no legal arguments. Cite no cases or statutes. I declare under penalty of perjury that the foregoing is true and correct. Signed this day of , 20. (Signature of Plaintiff) Complaint for Violation of Civil Rights (Prisoner Complaint) [Rev. 01/2018] 5 American LegalNet, Inc. www.FormsWorkFlow.com