PRO SE NON-PRISONER COMPLAINT PACKAGE Instructions - Read Carefully 1. Your complaint may be legibly handwritten or typewritten. In order for the United States District Court to consider this complaint, you must answer each question or fill in each blank clearly and simply. If you cannot finish an answer in the available space on the front of the page, you may continue the answer on another sheet of paper. If you continue an answer this way, make sure you identify clearly which question the continuation applies to. 2. Prepare an original and an identical copy of your proposed complaint and all attachments or exhibits to your proposed complaint for; (1) (2) THE COURT YOURSELF DO NOT MAIL A COPY OF YOUR COMPLAINT DIRECTLY TO ANY DEFENDANT(S). 3. Submit a check or money order in the amount of $350.00. Make the check or money order payable to the CLERK, U.S. DISTRICT COURT. If you cannot afford to prepay the fee, you must complete the affidavit of indigency (attached), declare it to be true and submit the affidavit with your proposed complaint. 4. IT IS YOUR RESPONSIBILITY TO KEEP A COPY FOR YOUR OWN FILE OF EVERY DOCUMENT OR LETTER THAT YOU SEND TO THE COURT. Please be advised that is not the court’s function to make or provide copies for litigants. 5. Mail your proposed complaint, your check or money order or affidavit of indigency to: Clerk, U.S. District Court Western District of Wisconsin P.O. Box 432 Madison, WI 53701-0432 (WDWI 8/2011) P:\Forms\42 USC 1983 American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WISCONSIN (Full name of plaintiff(s)) Case Number: vs (Supplied by clerk) (Full name of defendant(s)) COMPLAINT A. JURISDICTION 1._________________________________________________________, resides at (Plaintiff) _______________________________________, at __________________________________ (Address) (City, State) 2. Defendant ___________________________________________ is employed as (Name of First Defendant) ______________________________________ at ___________________________________ (Position and Title, if any) (Address) 3. Defendant ____________________________________________ is employed as (Name of Second Defendant) _____________________________________ at ___________________________________ (Position and Title, if any) (WDWI rev. 4/07 ) (Address) (Non-Prisoner Complaint) American LegalNet, Inc. www.FormsWorkFlow.com B. CAUSE OF ACTION On the space provided on the following pages, tell what specific incidents or conversations occurred which led you to believe your constitutional or federal rights have been or are presently being violated. IT IS IMPORTANT THAT THE ALLEGATIONS BE BRIEF, BUT SPECIFIC. Do not cite legal authorities, such as earlier court decisions or laws enacted by the legislature or Congress, to support your lawsuit at this early stage of your case. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (WDWI rev. 4/07 ) (Non-Prisoner Complaint) American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________________ (WDWI rev. 4/07 ) (Non-Prisoner Complaint) American LegalNet, Inc. www.FormsWorkFlow.com C. REQUEST FOR RELIEF 1. I ________________ request that I be allowed to commence this action without (do, do not) prepayment of fees and costs, or security therefor, pursuant to 28 U.S.C. §1915. The attached affidavit of indigency has been completed and is submitted in support of this request for leave to proceed in forma pauperis. 2. In the following space, please indicate exactly what it is you wish this court to do. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________ Dated this ________ day of _____________________, 20_____. _____________________________________________ (Signature) _____________________________________________ (Street or PO Box) _____________________________________________ (City, State Zip Code) _____________________________________________ (Area Code and Phone Number) (WDWI rev. 4/07 ) (Non-Prisoner Complaint) American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT WESTERN DISTRICT OF WISCONSIN ______________________________________ Full name of plaintiff(s) or petitioner(s) Case No. _______________________ (Provided by the clerk of court) v. ______________________________________ Full name of defendant(s) or respondent(s) PETITION AND AFFIDAVIT TO PROCEED WITHOUT PREPAYMENT OF FEES AND/OR COSTS I, ____________________________________________, declare that I am the plaintiff or petitioner in the above-named action. In support of my request to proceed in forma pauperis, I declare that I am unable to pay the fees and/or costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. I answer the following questions truthfully and under penalty of perjury (additional pages may be added, if necessary, to provide complete information): I. Personal Information 1) Are you currently incarcerated? G Yes G No If “No,” go to question 2. Complete all sections. If “Yes,” answer questions (a), (b) & (c), skip to Section IV. Complete sections IV and V. (a) State the place of your incarceration and provide your prisoner identification number: _______________________________________ (place) _____________________________ (number) GYes (b) Are you employed at the institution? (c) Do you receive any payment from the institution? GYes G No G No If you are a prisoner, attach a printout of your prison trust account statement showing transactions for the six-month period immediately preceding the filing of your complaint, motion, or petition and showing the balance of your release account. Prisoners who are permitted to file in forma pauperis must pay the full filing fee in installments. (WIWD 01/07) (WDWI rev. 4/07 ) (Non-Prisoner Complaint) American LegalNet, Inc. www.FormsWorkFlow.com Personal Information - continued 2) Are you employed? GYes G No 3) Are you currently married? If “Yes,” is your spouse employed? G Yes G Yes G No G No 4) Do you have any legal dependents (children/adults) whom you are responsible for supporting? G Yes G No If “Yes,” list them below: First and Last Initials (For Minor Children Only) or Name Relationship to You Age Amount of Support Provided Per Month ______________________________ _________________ ________ $____________ ______________________________ _________________ ________ $____________ ______________________________ _________________ ________ $____________ II. Income - If you are married, your answers must include your spouse's income. (When calculating income, you must include any salary, child support, public assistance, unemployment compensation, disability payments, life insurance payments, pensions, annuities, workers' compensation, stock dividends and interest, gifts, and inheritance, or other incoming monies.) State your total monthly income? $ ______________ Provide the name of your employer(s): _______________________________________ State your spouse's total monthly income? $ ______________ State the amount of money you have received from any other source in the last twelve months (e.g., rent payments, pension or insurance payments, gifts, inheritance, disability or workers’ compensation payments). Please attach an additional sheet if necessary. Source of income Amount ______________________________________________ $ ______________________ ______________________________________________ $ ______________________ (WDWI rev. 4/07 ) (Non-Prisoner Complaint) American LegalNet, Inc. www.FormsWorkFlow.com III. Expenses - If you are married and/or have dependents, your expenses should also include your household's expenses. (When calculating household expenses, you may include groceries, clothing, medical costs, utilities which are not included in your rental payments, transportation, and insurance.) 1) Identify the following amounts that you pay per month: G Rent or G Mortgage $ __________________________________ Car payment(s) $ __________________________________ Alimony and/or court-ordered child support $ __________________________________ Credit card payment(s) $ __________________________________ 2) Do you have any other monthly expenses that you have not already identified? G Yes G No If “Yes,” list them below: Expense Amount __________________________________ $ __________________________________ __________________________________ $ __________________________________ __________________________________ $ __________________________________ 3) What is the total amount of your monthly expenses? $____________________________ IV. Property - If you are married, your answers must include your spouse's property. 1 ) Do you own a car? G Yes G No If “Yes,” list car(s) below: Make and Model Year Approximate Current Value _______________________________________________ __________ $___________________________ _______________________________________________ __________ $___________________________ 2) Do you own your residence(s)? G Yes G No If “Yes,” state the approximate value(s). $ ____________________ What is the amount of equity (assessed value of residence minus outstanding mortgage balance) in the residence(s)? $ ____________________ (WDWI rev. 4/07 ) (Non-Prisoner Complaint) American LegalNet, Inc. www.FormsWorkFlow.com IV. Property - continued 3) Do you own any other valuable tangible property, including but not limited to, jewelry, artwork, or antiques? G Yes G No If “Yes,” identify the property and approximate value(s). Property Approximate Value ________________________________________________ $______________________ ________________________________________________ $______________________ ________________________________________________ $______________________ 4) Do you have any cash or checking, savings, or other similar accounts? G Yes G No If “Yes,” state the total amount of such sums. $ ____________________________________ 5) Do you own any intangible property, including but not limited to real estate, stocks, bonds, trusts, or individual retirement accounts (e.g., IRA, 401 k)? G Yes G No If “Yes,” state the nature of that property and approximate value(s). ____________________________________________________________________________ V. Other Circumstances - Describe any other financial circumstance(s) that you would like the court to consider when reviewing this petition. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ___________________________ Date (WDWI rev. 4/07 ) _________________________________________ Signature - Signed Under Penalty of Perjury (Non-Prisoner Complaint) American LegalNet, Inc. www.FormsWorkFlow.com