UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION CIVIL RIGHTS COMPLAINT FORM TO BE USED BY PRISONERS IN ACTIONS UNDER 28 U.S.C. § 1331 or § 1346 , Inmate # (Enter full name of Plaintiff) . vs. CASE NO: (To be assigned by Clerk) , , , , . (Enter name and title of each Defendant. If additional space is required, use the blank area below and directly to the right.) ANSWER ALL QUESTIONS ON THE FOLLOWING PAGES: American LegalNet, Inc. www.FormsWorkflow.com I. PLAINTIFF: State your full name, inmate number (if applicable), and full mailing address in the lines below. Name of Plaintiff: Inmate Number Prison or Jail: Mailing address: II. DEFENDANT(S): State the name of the Defendant in the first line, official position in the second line, place of employment in the third line, and mailing address. Do the same for every Defendant: (1) Defendant's name: Official position: Employed at: Mailing address: (2) Defendant's name: Official position: Employed at: Mailing address: (3) Defendant's name: Official position: Employed at: Mailing address: ATTACH ADDITIONAL PAGES HERE TO NAME ADDITIONAL DEFENDANTS 2 American LegalNet, Inc. www.FormsWorkflow.com III. EXHAUSTION OF ADMINISTRATIVE REMEDIES Pursuant to 42 U.S.C. § 1997e(a), exhaustion of administrative remedies is required prior to initiating a civil rights action which alleges unlawful conditions or events in any prison, jail, or detention center. Plaintiff is warned that any claims for which the administrative grievance process was not completed prior to filing this lawsuit may be subject to dismissal. IV. PREVIOUS LAWSUITS NOTE: FAILURE TO DISCLOSE ALL PRIOR CIVIL CASES MAY RESULT IN THE DISMISSAL OF THIS CASE. IF YOU ARE UNSURE OF ANY PRIOR CASES YOU HAVE FILED, THAT FACT MUST BE DISCLOSED AS WELL. A. Have you initiated other actions in state court dealing with the same or similar facts/issues involved in this action? Yes( ) No( ) 1. Parties to previous action: (a) Plaintiff(s): (b) Defendant(s): 2. Name of judge: Case #: 3. County and judicial circuit: 4. Approximate filing date: 5. If not still pending, date of dismissal: 6. Reason for dismissal: 7. Facts and claims of case: (Attach additional pages as necessary to list state court cases.) B. Have you initiated other actions in federal court dealing with the same or similar facts/issues involved in this action? Yes( ) 1. Parties to previous action: a. Plaintiff(s): b. No( ) Defendant(s): 2. District and judicial division: 3. Name of judge: 4. Approximate filing date: 5. If not still pending, date of dismissal: 6. Reason for dismissal: Case #: 3 American LegalNet, Inc. www.FormsWorkflow.com 7. Facts and claims of case: (Attach additional pages as necessary to list other federal court cases.) C. Have you initiated other actions (besides those listed above in Questions (A) and (B)) in either state or federal court that relate to the fact or manner of your incarceration (including habeas corpus petitions) or the conditions of your confinement (including civil rights complaints about any aspect of prison life, whether it be general circumstances or a particular episode, and whether it involved excessive force or some other wrong)? Yes( ) No( ) If YES, describe each action in the space provided below. If more than one action, describe all additional cases on a separate piece of paper, using the same format as below. 1. Parties to previous action: a. Plaintiff(s): b. Defendant(s): 2. District and judicial division: 3. Name of judge: 4. Approximate filing date: 5. If not still pending, date of dismissal: 6. Reason for dismissal: 7. Facts and claims of case: Case #: (Attach additional pages as necessary to list cases.) D. Have you ever had any actions in federal court dismissed as frivolous, malicious, failing to state a claim, or prior to service? If so, identify each and every case so dismissed: Yes( ) 1. Parties to previous action: a. Plaintiff(s): b. No( ) Defendant(s): 2. District and judicial division: 3. Name of judge: Case Docket # 4. Approximate filing date: Dismissal date: 5. Reason for dismissal: 4 American LegalNet, Inc. www.FormsWorkflow.com 6. Facts and claims of case: (Attach additional pages as necessary to list cases.) V. STATEMENT OF FACTS: State briefly the FACTS of this case. Describe how each Defendant was involved and what each person did or did not do which gives rise to your claim. In describing what happened, state the names of persons involved, dates, and places. Do not make any legal arguments or cite to any cases or statutes. You must set forth separate factual allegations in separately numbered paragraphs. You may make copies of this page if necessary to supply all the facts. Barring extraordinary circumstances, no more than five (5) additional pages should be attached. (If there are facts which are not related to this same basic incident or issue, they must be addressed in a separate civil rights complaint.) 5 American LegalNet, Inc. www.FormsWorkflow.com 6 American LegalNet, Inc. www.FormsWorkflow.com VI. STATEMENT OF CLAIMS: State what rights under the Constitution, laws, or treaties of the United States you claim have been violated. Be specific. Number each separate claim and relate it to the facts alleged in Section V. If claims are not related to the same basic incident or issue, they must be addressed in a separate civil rights complaint. VII. RELIEF REQUESTED: State briefly what relief you seek from the Court. Do not make legal arguments or cite to cases/ statutes. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS OF FACT, INCLUDING ALL CONTINUATION PAGES, ARE TRUE AND CORRECT. (Date) (Signature of Plaintiff) IF MAILED BY PRISONER: I declare (or certify, verify, or affirm) under penalty of perjury that this complaint was (check one): G delivered to prison officials for mailing or G deposited in the prison's internal mail system on: the day of , 20 . (Signature of Plaintiff) Revised 03/07 7 American LegalNet, Inc. www.FormsWorkflow.com