CIVIL RIGHTS COMPLAINT PURSUANT TO 42 U.S.C. § 1983 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF GEORGIA ____________________________________ (Enter above the full name and prisoner identification number of the plaintiff, GDC number if a state prisoner.) -vs____________________________________ ____________________________________ ____________________________________ (Enter above the full name of the defendant(s).) I. Previous Lawsuits A. Have you filed other lawsuits in federal court while incarcerated in any institution? Yes ( B. ) No ( ) If your answer to A is yes, describe each lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on another piece of paper, using the same outline.) 1. Parties to this previous lawsuit: Plaintiff(s): _________________________________________________ _________________________________________________ Defendant(s): _________________________________________________ _________________________________________________ 2. Court (name the district): _____________________________________________________________ _____________________________________________________________ Docket Number: ___________________________________________ 3. Rev. 12/5/07 American LegalNet, Inc. www.FormsWorkflow.com I. Previous Lawsuits (Cont'd) 4. 5. Name of judge to whom case was assigned: _________________________ Did the previous case involve the same facts? Yes ( 6. ) No ( ) Disposition (Was the case dismissed? Was it appealed? Is it still pending?): _____________________________________________________________ _____________________________________________________________ Approximate date of filing lawsuit: _______________________________ Approximate date of disposition: _______________________________ 7. 8. II. Exhaustion of Administrative Remedies Pursuant to 28 U.S.C. § 1997e(a), no prisoner civil rights action shall be brought in federal court until all available administrative remedies are exhausted. Exhaustion of administrative remedies is a precondition to suit, and the prisoner plaintiff must establish that he has exhausted the entire institutional grievance procedure in order to state a claim for relief. A. B. Place of Present Confinement: _____________________________________ Is there a prisoner grievance procedure in this institution? Yes ( ) No ( ) C. Did you present the facts relating to your complaint under the institution's grievance procedure? Yes ( ) No ( ) D. If your answer is YES: 1. What steps did you take and what were the results? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 2. If your answer is NO, explain why not: ________________________ ____________________________________________________________ ____________________________________________________________ Rev. 12/5/07 American LegalNet, Inc. www.FormsWorkflow.com III. Parties (In item A below, place your name in the first blank and place your present address in the second blank.) A. Name of Plaintiff: _________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Address(es): _______________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ (In item B below, place the full name of the defendant in the first blank, his/her official position in the second blank, and his/her place of employment in the third blank. Do the same for each additional defendant, if any.) B. Defendant(s): _____________________________________________________ _________________________________________________________________ _________________________________________________________________ Employed as _____________________________________________________ _________________________________________________________________ at _______________________________________________________________ _________________________________________________________________ IV. Statement of Claim State here as briefly as possible the facts of your case. Describe how each defendant is involved. Include also the names of other persons involved, dates, and places. Do not give any legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate paragraph. (Use as much space as you need. Attach extra sheets if necessary.) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Rev. 12/5/07 American LegalNet, Inc. www.FormsWorkflow.com IV. Statement of Claim (Cont'd) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ______________________________________