_______________________________________ (full name/prisoner number) _______________________________________ _______________________________________ _______________________________________ (complete mailing address) UNITED STATES DISTRICT COURT FOR THE DISTRICT OF IDAHO _____________________________________, (full name) Case No. Plaintiff, (to be assigned by Court) v. PRISONER COMPLAINT ____________________________________ ____________________________________ ____________________________________ ____________________________________ Defendant(s). (if you need additional space, use a blank page for a continuation page) Jury Trial Requested: ____ Yes ____ No A. JURISDICTION The United States District Court for the District of Idaho has jurisdiction over my claims under: (check all that apply): ____ 42 U.S.C. � 1983 (applies to state, county, or city defendants) ____ Bivens v. Six Unknown Named Agents of Fed. Bureau of Narcotics, 403 U.S. 388 (1971) and 28 U.S.C. � 1331 (applies to federal government defendants only) ____ Other federal statute (specify) ______________; or diversity of citizenship. ____ I also ask the federal court to exercise supplemental jurisdiction over state law claims. B. PLAINTIFF My name is ________________________________. I am a citizen of the State of _____________, presently residing at _______________________________________________________________. PRISONER COMPLAINT - p. 1_ (Rev. 10/24/2011) American LegalNet, Inc. www.FormsWorkFlow.com C. DEFENDANT(S) AND CAUSE(S) OF ACTION (Copy and use a separate page for each defendant and each different type of claim; for example, if you have two different claims against one defendant, you will use two pages. Attach a continuation page if needed, but try to be brief.) 1. I am suing _____________________________, who was acting as __________________________ (defendant) (job title, if a person; function, if an entity) for the ____________________________________________________________________________. (state, county, city, federal government, or private entity performing a public function) 2. (Factual Basis of Claim) I am complaining that on ______________________________, Defendant did (dates) the following (state how Defendant participated in the violation and include the reason Defendant so acted if known): ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 3. (Legal Basis of Claim) I allege that the acts described above violated the following provisions of the Constitution, federal statutes, or state laws: ___________________________________________________________________________________ ___________________________________________________________________________________ 4. I allege that I suffered the following injury or damages as a result: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 5. I seek the following relief: ___________________________________________________________ ___________________________________________________________________________________ 6. I am suing Defendant in his/her __ personal capacity (money damages from Defendant personally), and/or __ official capacity (seeking an order for Defendant to act or stop acting in a certain way; or money damages from an entity because of Defendant's acts, as allowed by law); or __ Defendant is an entity (government or private business). 7. For this claim, I exhausted the grievance system within the jail or prison in which I am incarcerated. ____Yes ____No. If "Yes," briefly explain the steps taken to exhaust; if "No," briefly explain why full jail or prison grievance remedies were not exhausted. PRISONER COMPLAINT - p. 2_ (Rev. 10/24/2011) American LegalNet, Inc. www.FormsWorkFlow.com ____________________________________________________________________________________________ D. PREVIOUS OR PENDING LAWSUITS I have pursued or am now pursuing the following other lawsuits: (include (1) all lawsuits in state or federal court related to the subject matter of this action, and (2) any federal court civil rights lawsuits, related or unrelated, and note whether you have received a strike under 28 U.S.C. � 1915(g) for filing a complaint that is frivolous, malicious, or fails to state a claim upon which relief can be granted.) Court _________ _________ _________ Case No. _________ _________ _________ Case Name ____________________________ ____________________________ ____________________________ Status of Case Strike? _______________________ ____ _______________________ ____ _______________________ ____ E. REQUEST FOR APPOINTMENT OF ATTORNEY I do___ do not _____ request that an attorney be appointed to represent me in this matter. I believe that I am in need of an attorney for these particular reasons which make it difficult for me to pursue this matter without an attorney: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ F. DECLARATION UNDER PENALTY OF PERJURY I declare under penalty of perjury: that I am the plaintiff in this action, that I have read the complaint, and that the information contained in the complaint is true and correct. 28 U.S.C. � 1746; 18 U.S.C. � 1621; and that I deposited this complaint postage prepaid in a United States postal depository unit on ___________(date); OR that I gave the