FULL NAME COMMITTED NAME (if different) FULL ADDRESS INCLUDING NAME OF INSTITUTION PRISON NUMBER (if applicable) UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA CASE No. CV (To be supplied by the Clerk) PLAINTIFF , v. CIVIL RIGHTS COMPLAINT PURSUANT TO (check one) G 42 U.S.C. § 1983 or G Bivens v. Six Unknown Agents 403 U.S. 388 (1971); DEFENDANT(S). A. PREVIOUS LAWSUITS 1) Have you brought any other lawsuits in a federal court while a prisoner: G Yes G No 2) If your answer to 1 is yes, how many? Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on an attached piece of paper using the same outline.) Page 1 of 6 CV-66 (7/97) CIVIL RIGHTS COMPLAINT FORM 2001 © American LegalNet, Inc. a. Parties to this previous lawsuit: Plaintiff Defendants b. Court c. d. e. Docket or case number Name of judge to whom case was assigned Disposition (For example: Was the case dismissed? If so, what was the basis for dismissal? Was it appealed? Is it still pending?) f. Issues raised: g. h. Approximate date of filing lawsuit Approximate date of disposition B. EXHAUSTION OF ADMINISTRATIVE REMEDIES 1) Is there a grievance procedure available at the institution where the events relating to your current complaint occurred? 2) G Yes G No Have you filed a grievance concerning the facts relating to your current complaint? G Yes G No If your answer is no, explain why not 3) Is the grievance procedure completed? G Yes G No Page 2 of 6 CV-66 (7/97) CIVIL RIGHTS COMPLAINT FORM 2001 © American LegalNet, Inc. If your answer is no, explain why not 4) Please attach copies of papers related to the grievance procedure. C. JURISDICTION This complaint alleges that the civil rights of plaintiff (print plaintiff's name) who presently resides at (mailing address or place of confinement) , were violated by the actions of the defendant(s) named below, which actions were directed against plaintiff at (institution/city where violation occurred) on (date or dates) (Claim I) , (Claim II) , (Claim III) . (You need not name more than one defendant or allege more than one claim; however, make a copy of this page to provide the information below if you are naming more than five (5) defendants.) 1) Defendant (full name of first defendant) resides or works at (full address of first defendant) (defendant's position and title, if any) The defendant is sued in his/her: G individual G official capacity. (Check one or both). Explain how this defendant was acting under color of law: 2) Defendant (full name of second defendant) resides or works at , and is employed as (full address of second defendant) . (defendant's position and title, if any) The defendant is sued in his/her: G individual G official capacity. (Check one or both.) Explain how this defendant was acting under color of law: Page 3 of 6 CV-66 (7/97) CIVIL RIGHTS COMPLAINT FORM 2001 © American LegalNet, Inc. 3) Defendant (full name of third defendant) (full address of third defendant) resides or works at , and is employed as . (defendant's position and title, if any) The defendant is sued in his/her: G individual G official capacity. (Check one or both.) Explain how this defendant was acting under color of law: 4) Defendant (full name of fourth defendant) resides or works at , and is employed as (full address of fourth defendant) (defendant's position and title, if any) . The defendant is sued in his/her: G individual G official capacity. (Check one or both.) Explain how this defendant was acting under color of law: 5) Defendant (full name of fifth defendant) (full address of fifth defendant) (defendant's position and title, if any) resides or works at , and is employed as . The defendant is sued in his/her: G individual G official capacity. (Check one or both.) Explain how this defendant was acting under color of law: Page 4 of 6 CV-66 (7/97) CIVIL RIGHTS COMPLAINT FORM 2001 © American LegalNet, Inc. E. CLAIMS* CLAIM I The following civil right has been violated: Supporting Facts: [Include all facts you consider important. State the facts clearly, in your own words, and without citing legal authority or argument. Be certain you describe, in separately numbered paragraphs, exactly what each DEFENDANT (by name) did to violate your right.] *If there is more than one claim, describe the additional claim(s) on another attached piece of paper using the same outline. PAGE 5 OF 6 CV-66 (7/97) CIVIL RIGHTS COMPLAINT FORM 2001 © American LegalNet, Inc. F. REQUEST FOR RELIEF I believe that I am entitled to the following specific relief: (Date) (Signature of Plaintiff) Page 6 of 6 CV-66 (7/97) CIVIL RIGHTS COMPLAINT FORM 2001 © American LegalNet, Inc.