UNITED STA TES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION CIVIL RIGHTS COMPLAINT FORM TO BE USED BY PRO SE (NON-PRISONER) LITIGANTS IN ACTIONS UNDER 28 U.S.C. 1331 or 1346 OR 42 U.S.C. 1983 , . (Enter full name of Plaintiff(s)) 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 A LL QUESTION S ON THE FOLLOWING PAGES: >>>> 2I. PLA INTIFF: State your full name and full mailing address in the lines below. Name of Plaintiff: Mailing address: II. DEFEN DANT(S): State the name of the Defendant in the first line, official position in the second line, place ofemployment in the third line, and mailing address. Do the same for every Defendant:(1) Defendants name: Official position: Employed at: Mailing address: (2) Defendants name: Official position: Employed at: Mailing address: (3) Defendants name: Official position: Employed at: Mailing address: (4) Defendants name: Official position: Employed at: Mailing address: ATTACH ADDITIONAL PAGES HERE TO NAME ADDITIONAL DEFENDANTS 2>>>> 3III. STA TEMENT OF FACTS: Sta te briefly the FACTS of t his case. Describe how each Defendant was involved and what eachperson did or did not do which gives rise to your claim. In describing what happened, stat e the names ofpersons involved, dates, and places. Do not make any legal argum ents or cite to any cases or st atutes. Youmust se t forth se para te fac tual allega tions in sepa rately numbered paragraphs. You may make copies of thispage if necess ary to supply all the facts. Barring extraordinary circumstances, no m ore than five (5) additionalpages should be attached. (If there are facts which are not rel ated to t his same basic i ncident or i ssue,they m ust be a ddres sed in a se parate civil rights co mp laint.) 3 >>>> 4IV. STA TEMENT OF CLA IMS: State what rights under the C onstitution, laws, or treaties of the United States you claim havebee n violated. Be specific. Number each separate claim and relate it to the facts alleged in Section III. Ifclaims are n ot related to the sam e basic incid ent or issu e, they m ust be a ddres sed in a se paratecivil rights com plaint. V. RELIEF REQUESTED: Stat e briefly what relief you seek from the Court. Do not make lega l arguments or cite to cases/ st atutes. I DECL AR E UNDE R PEN AL TY OF P ERJ URY THA T THE F OREGOI NG STA TEMENTS OF FA CT,INCLUDI NG A LL CONT INUA TION PA GES, AR E TRUE AND CORRE CT. (Date) (Signature of Plaintiff)Revised 07/02 4