INSTRUCTIONS FOR FILING CIVIL RIGHTS COMPLAINT UNDER 42 U.S.C. 247 1983 IN THE UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF CALIFORNIA (1) This complaint must be legibly handwritten or typewritten, and signed by the plaintiff. All questions must be answered concisely in the proper space on the form. Do NOT write on the back of any page. No citation of case or statutory authority is necessary. (2) Additional pages not to exceed fifteen (15) in number may be included with the court approved form complaint, provided the form is completely filled in to the extent applicable in the particular case. This limitation does not include exhibits. (3) Upon receipt of a fee of $400 ($350 statutory fee and $50 administrative fee) your complaint will be filed if it is in proper order. The $400 fee must be submitted with the complaint, not separately. (4) If you do not have the necessary funds to pay the filing fee or cannot afford to pay for transcripts, counsel, appeal, or other costs connected with this civil action, you may request permission to proceed in forma pauperis, in which event you must execute a separate form provided by the Court, entitled 223Motion and Declaration Under Penalty of Perjury in Support of Motion to Proceed In Forma Pauperis224 setting forth information establishing your inability to pay fees or costs. IF YOU ARE A PRISONER, you must attach a certified copy of your prison trust account statements for the 6-month period immediately preceding the filing of the complaint per 28 U.S.C. 247 1915(a)(2) or your motion to proceed in forma pauperis will be denied. Even if your motion to proceed in forma pauperis is granted, however, the Court may assess an initial partial filing fee at the time your action is file and the $50 administrative fee will be waived. After the initial partial fee is assessed, YOU WILL STILL OWE THE BALANCE OF THE $350 STATUTORY FILING FEE WHICH THE COURT WILL ORDER GARNISHED FROM YOUR PRISON TRUST ACCOUNT. (5) When the complaint is fully completed, it must be mailed to: Clerk of U.S. District Court 333 West Broadway, Suite 420 San Diego, CA 92101 American LegalNet, Inc. www.FormsWorkFlow.com (Name)(Address)(City, State, Zip)(CDCR / Booking / BOP No.)United States District CourtSouthern District of California , )(Enter full name of plaintiff in this action.)) )Plaintiff,) Civil Case No. )(To be supplied by Court Clerk)v.)),)Complaint under the,)Civil Rights Act,)42 U.S.C. 247 1983,)(Enter full name of each defendant in this action.))Defendant(s).))A. JurisdictionJurisdiction is invoked pursuant to 28 U.S.C. 247 1343(a)(3) and 42 U.S.C. 247 1983. If you wish toassert jurisdiction under different or additional authority, list them below..B. Parties1. Plaintiff : This complaint alleges that the civil rights of Plaintiff, (print Plaintiff222s name), who presently resides at (mailing address or place of confinement) , were violated by the actions ofthe below named individuals. The actions were directed against Plaintiff at on (dates) , , and . (institution/place where violation occurred) (Count 1) (Count 2) (Count 3)247 1983 SD Form(Rev. 8/15) American LegalNet, Inc. www.FormsWorkFlow.com 2. Defendants : (Attach same information on additional pages if you are naming more than 4 defendants.)Defendant resides in , (name)(County of residence)and is employed as a . This defendant is sued in(defendant222s position/title (if any))his/her individual official capacity. (Check one or both.) Explain how this defendant was acting undercolor of law: .Defendant resides in , (name)(County of residence)and is employed as a . This defendant is sued in(defendant222s position/title (if any))his/her individual official capacity. (Check one or both.) Explain how this defendant was acting undercolor of law: .Defendant resides in , (name)(County of residence)and is employed as a . This defendant is sued in(defendant222s position/title (if any))his/her individual official capacity. (Check one or both.) Explain how this defendant was acting undercolor of law: .Defendant resides in , (name)(County of residence)and is employed as a . This defendant is sued in(defendant222s position/title (if any))his/her individual official capacity. (Check one or both.) Explain how this defendant was acting undercolor of law: .2247 1983 SD Form(Rev. 8/15) American LegalNet, Inc. www.FormsWorkFlow.com C. Causes of Action(You may attach additional pages alleging other causes of action and the facts supportingthem if necessary.)Count 1 : The following civil right has been violated:(E.g., right to medical care, access to courts,.due process, free speech, freedom of religion, freedom of association, freedom from cruel and unusual punishment, etc.)Supporting Facts : [Include all facts you consider important to Count 1. State what happened clearly and in yourown words. You need not cite legal authority or argument. Be certain to describe exactly what each defendant, by name,did to violate the right alleged in Count 1.] .3247 1983 SD Form(Rev. 8/15) American LegalNet, Inc. www.FormsWorkFlow.com Count 2 : The following civil right has been violated: (E.g., right to medical care, access to courts,.due process, free speech, freedom of religion, freedom of association, freedom from cruel and unusual punishment, etc.)Supporting Facts : [Include all facts you consider important to Count 2. State what happened clearly and in your ownwords. You need not cite legal authority or argument. Be certain to describe exactly what each defendant, by name, did toviolate the right alleged in Count 2.].4247 1983 SD Form(Rev. 8/15) American LegalNet, Inc. www.FormsWorkFlow.com Count 3 : The following civil right has been violated:(E.g., right to medical care, access to courts,.due process, free speech, freedom of religion, freedom of association, freedom from cruel and unusual punishment, etc.)Supporting Facts : [Include all facts you consider important to Count 3. State what happened clearly and in your ownwords. You need not cite legal authority or argument. Be certain to describe exactly what each defendant, by name, did toviolate the right alleged in Count 3.].5247 1983 SD Form(Rev. 8/15) American LegalNet, Inc. www.FormsWorkFlow.com D. Previous Lawsuits and Administrative Relief1. Have you filed other lawsuits in state or federal courts dealing with the same or similar factsinvolved in this case? Yes No. If your answer is "Yes", describe each suit in the space below. [If more than one, attach additional pagesproviding the same information as below.](a)Parties to the previous lawsuit:Plaintiffs: Defendants: (b)Name of the court and docket number: .(c)Disposition: [ For example, was the case dismissed, appealed, or still pending?] .(d)Issues raised: .(e)Approximate date case was filed: .(f)Approximate date of disposition: .2.Have you previously sought and exhausted all forms of available relief from the properadministrative officials regarding the acts alleged in Part C above? [E.g., CDCR Inmate/Parolee Appeal Form602, etc.] ? Yes No.If your answer is "Yes", briefly describe how relief was sought and the results. If your answer is "No",briefly explain why administrative relief was not exhausted. . 6247 1983 SD Form(Rev. 8/15) American LegalNet, Inc. www.FormsWorkFlow.com E. Request for ReliefPlaintiff requests that this Court grant the following relief:1.An injunction preventing defendant(s):.2.Damages in the sum of $ .3.Punitive damages in the sum of $ .4.Other:.F.Demand for Jury TrialPlaintiff demands a trial by Jury Court. (Choose one.)G.Consent to Magistrate Judge JurisdictionIn order to insure the just, speedy and inexpensive determination of Section 1983 Prisoner cases filed inthis district, the Court has adopted a case assignment involving direct assignment of these cases tomagistrate judges to conduct all proceedings including jury or bench trial and the entry of final judgmenton consent of all the parties under 28 U.S.C. 247 636(c), thus waiving the right to proceed before a districtjudge. The parties are free to withhold consent without adverse substantive consequences.The Court encourages parties to utilize this efficient and expeditious program for case resoluti