INMATE FORM FOR CIVIL ACTION INSTRUCTIONS – READ CAREFULLY (NOTE: O.C.G.A. §9-10-14(a) requires the proper use of this form, and failure to use this form as required will result in the clerk of any court refusing to accept the action for filing.) 1. Any action filed by an inmate of a state or local penal or correctional institution against the state or a local government or against any agency or officer of a state or local government must be filed on the appropriate form or forms promulgated by the Administrative Office of the Courts of Georgia. 2. This application must be legibly handwritten or typewritten, and signed by the petitioner. Any false statement of a material fact may serve as the basis for prosecution for perjury. All questions must be answered concisely in the proper space on the form. 3. O.C.G.A. §42-12-1 et seq. provides that an inmate’s institutional account shall be frozen, and funds seized for court costs and fees. Additionally, the filing of frivolous litigation shall result in a deduction from the account. 4. Any inmate may submit with the complaint or other initial pleading any additional matter in any form if the pleading includes the form or forms attaches hereto. Material attached to the forms should be legibly handwritten, typewritten, or copied. 5. Upon receipt of the appropriate filing fee or if permission to proceed in forma pauperis has been granted, your petition will be filed if it is in proper order. 6. If the inmate wishes to file an affidavit of indigency, it must be accompanied by a certification from the institution wherein the inmate is incarcerated that the financial statement correctly states the amount of funds in any and all custodial accounts held with the institution. 7. Any Inmate Form for Civil Action which does not conform to these instructions will be returned with a notation as to the deficiency. 8. These forms may be obtained at the Administrative Office of the Courts’ website (http://www.georgiacourts.org/forms.html#inmate) or from the Administrative Office of the Courts through the head of the institution in which the inmate is incarcerated. American LegalNet, Inc. www.FormsWorkflow.com IN THE SUPERIOR COURT OF ___________________________ STATE OF GEORGIA ____________________________________ , Plaintiff ____________________________________ , Inmate Number Civil Action No. _________________________ vs. ____________________________________ , Nature of Action: _______________________________________ ____________________________________ , _______________________________________ ____________________________________, Defendant(s) _______________________________________ INMATE FORM FOR CIVIL ACTION PART I: BACKGROUND INFORMATION ON YOUR CONVICTION 1. Name and location of prison in which you are now confined: ________________________________ _________________________________________________________________________________ 2. Sentence you are now serving: _______________________________________________________ _________________________________________________________________________________ Name and location of court which imposed sentence: _______________________________________ _________________________________________________________________________________ Approximate date your sentence will be completed: ________________________________________ 3. The indictment number or numbers (if known) upon which, and the offense or offenses for which sentence was imposed: a. _______________________________________________________________________________ ________________________________________________________________________________ b. _______________________________________________________________________________ ________________________________________________________________________________ c. _______________________________________________________________________________ ________________________________________________________________________________ 4. Give the approximate date upon which sentence was imposed and the terms of the sentence: a. _______________________________________________________________________________ ________________________________________________________________________________ b. _______________________________________________________________________________ Administrative Office of the Courts (Revised 02-10-09) [1] Form CA-1 American LegalNet, Inc. www.FormsWorkflow.com ________________________________________________________________________________ c. _______________________________________________________________________________ ________________________________________________________________________________ 5. Check whether a finding of guilty was made after a plea of: Guilty Guilty but mentally ill Nolo contendere Not guilty 6. If you were found guilty after a plea of not guilty, check whether the finding was made by: Jury Judge only 7. Did you appeal from the judgment of conviction or the imposition of sentence? Yes No 8. If you did appeal, answer the following: a. The name of each court to which you appealed: 1. ____________________________________________________________________________ 2. ____________________________________________________________________________ 3. ____________________________________________________________________________ b. The result in each such court to which you appealed: 1. ____________________________________________________________________________ 2. ____________________________________________________________________________ 3. ____________________________________________________________________________ c. The approximate date of each such result: 1. ____________________________________________________________________________ 2. ____________________________________________________________________________ 3. ____________________________________________________________________________ d. If known, citations of any written opinion orders entered pursuant to such results: 1. ____________________________________________________________________________ 2. ____________________________________________________________________________ 3. ____________________________________________________________________________ PART II: OTHER LAWSUITS 9. OTHER THAN LAWSUITS ALREADY LISTED in questions 3 through 8, have you ever begun or are you now beginning other lawsuits in federal or state courts dealing with the same facts involved in this action or relating to your imprisonment? Yes No Administrative Office of the Courts (Revised 02-10-09) [2] Form CA-1 American LegalNet, Inc. www.FormsWorkflow.com 10. If your answer to number 9 is “Yes,” describe the 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 for each lawsuit.) a. Parties to the previous lawsuit: Plaintiffs: _______________________________________________________________ ________________________________________________________________________ Defendants: _____________________________________________________________ ________________________________________________________________________ b. Court (If federal court, name the district. If state court, name the court and county) : ______________________________________________________________________________ c. Docket Number: _____________________________________________________________ d. Name of judge to whom case was assigned: ________________________________________ ______________________________________________________________________________ e. Date on which you filed lawsuit: _________________________________________________ f. Date of disposition, if any, of lawsuit: _____________________________________________ g. What was the lawsuit about? ____________________________________________________ ______________________________________________________________________________ h. What was the outcome of the lawsuit? (For example, was the case dismissed? Was it appealed? Is it still pending? _______________________________________________________ i. Citations, if known, to any written opinions or orders in the lawsuit: _____________________ ______________________________________________________________________________ PART III: GRIEVANCE PROCEDURES 11. Is there a prisoner grievance procedure at the institution in which you are presently confined? Yes 12. No If your answer to number 11 is “Yes,” please answer the following: a. Did you present the facts relating to your complaint in the institution’s prisoner grievance procedures? Yes No b. If your answer to (a) above is “Yes,” What steps did you take? _______________________________________________________ ____________________________________________________________________________ What was the result? __________________________________________________________ ____________________________________________________________________________ c. If your answer to (a) above is “No,” explain why not: ________________________________ ____________________________________________________________________________ Administrative Office of the Courts (Revised 02-10-09) [3] Form CA-1 American LegalNet, Inc. www.FormsWorkflow.com ____________________________________________________________________________ 13. Tell what you have done, other than what you have described in question 12, to bring your complaints to the attention of prison officials. In doing so, give dates, places, and names of persons talked to. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 14. Names and approximate dates of entry and exit, and locations of all prisons and jails in which you have been incarcerated: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 15. As to your present confinement, please state: a. Which part of the penitentiary or jail are you held in : ________________________________ ___________________________________________________________________________ b. How long have you been in this part of the penitentiary or jail? ________________________ ___________________________________________________________________________ c. Please list the full name of every prisoner now confined in the same general area: __________ ___________________________________________________________________________ ____________________________________________________________________________ PART IV: STATEMENT OF CLAIMS 16. List the name and address of each plaintiff in this lawsuit: _______________________________ ______________________________________________________________________________ ______________________________________________________________________________ 17. List below for each defendant, the defendant’s full name, official position, and place of employment. Attach additional paper if necessary. Full Name Official Position Place of Employment ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Administrative Office of the Courts (Revised 02-10-09) [4] Form CA-1 American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ STATEMENT OF CLAIM 18. Describe each and every FACT—no opinions or views, only the actual events—supporting and explaining the basis for the lawsuit you have filed. DESCRIBE HOW EACH DEFENDANT IS INVOLVED. Include also the names of other persons involved, dates and places. If you intend to allege a number of related claims, you should number and set forth each claim separately. DO NOT GIVE ANY LEGAL ARGUMENT OR CITE ANY CASES OR STATUTES. (You may attach additional sheets of paper if necessary.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 19. List the name and present address of every person who you believe was a witness to the facts set forth in number 18 and BRIEFLY state what each person knows (from having seen, heard, etc.) concerning what happened. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Administrative Office of the Courts (Revised 02-10-09) [5] Form CA-1 American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 20. Please describe any legal argument you wish to make. You may add separate sheets of paper if necessary. It is not necessary that you present legal argument in order to obtain the relief to which you are entitled. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 21. Briefly state the specific relief requested against each party. This means to state exactly what you want the court to do for you. DO NOT MAKE ANY LEGAL ARGUMENTS. DO NOT CITE CASES OR STATUTES. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Administrative Office of the Courts (Revised 02-10-09) [6] Form CA-1 American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ I declare (or certify, verify, or state) under penalty of perjury that the foregoing statements made in this Inmate Form for Civil Action are true and correct. Executed on __________________________ Date _____________________________________________ Signature of Plaintiff Sworn to and subscribed before me this _______ day of ______________, 20____. ___________________________________________________ Notary Public or Other Person Authorized to Administer Oaths Administrative Office of the Courts (Revised 02-10-09) [7] Form CA-1 American LegalNet, Inc. www.FormsWorkflow.com