A COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983 UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF LOUISIANA Plaintiff Inmate Number VERSUS (Enter above the full name of each defendant in this action.) Electronic Filing Pilot Program In accordance with the Procedural Rules for Electronic Filing Pilot Project, General Order 2012-01, inmates who reside in or are transferred into Louisiana Department of Corrections facilities participating in the Electronic Filing Pilot Program shall receive orders, notices and judgments by Notice of Electronic Filing ("NEF"). Instructions for Filing Complaint by Prisoners Under the Civil Rights Act, 42 U.S.C. § 1983. The names of all parties must be listed in the caption and in part III of the complaint exactly the same. In order for this complaint to be filed, it must be accompanied by the filing fee of $350.00. In addition, the United States Marshal will require you to pay the cost of serving the complaint on each of the defendants. If you are unable to pre-pay the filing fee and service costs, you may petition the court to proceed in forma pauperis. You must sign the affidavit, and obtain the signature of an authorized officer certifying the amount of money in your inmate account. If pauper status is granted, you will be required to pay an initial partial filing fee and thereafter, prison officials shall be ordered to forward monthly payments from your inmate account until the entire filing fee is paid. American LegalNet, Inc. www.FormsWorkFlow.com You will note that you are required to give facts. THIS COMPLAINT SHOULD NOT CONTAIN LEGAL ARGUMENTS OR CITATIONS. ALSO, DO NOT INCLUDE EXHIBITS. Submit the complaint and pauper affidavit to the Clerk of the United States District Court for the Middle District of Louisiana, 777 Florida Street, Suite 139, Baton Rouge, La. 70801-1712. I. Previous Lawsuits A. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action or otherwise relating to your imprisonment? Yes ( ) No ( ) B. 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 (if federal court, name the district; if state court, name the parish): 3. Docket number: 4. Name of judge to whom case was assigned: 5. Disposition (for example: Was the case dismissed? Was it appealed? Is it still pending?): 6. Date of filing lawsuit: 7. Date of disposition: C. Have you had any previously filed federal lawsuits or appeals, whether or not related to the issues raised in this complaint, dismissed by any federal court as frivolous, malicious, or for failure to state a claim for which relief can be granted? Yes ( ) No ( ) American LegalNet, Inc. www.FormsWorkFlow.com If your answer is yes, list the civil action numbers and the disposition of each case. You must identify in which federal district or appellate court the action was brought. II. Place of present confinement: A. Is there a prisoner grievance procedure in this institution? Yes ( ) No ( ) B. Did you present the facts relating to your complaint in the state prisoner grievance procedure? Yes ( ) No ( ) C. If your answer is Yes: 1. Identify the administrative grievance procedure number(s) in which the claims raised in this complaint were addressed. 2. What steps did you take? 3. What was the result? D. If your answer is No, explain why not: III. Parties (In Item A below, place your name in the first blank and place your present address in the second blank. Do the same for additional plaintiffs, if any.) A. Name of plaintiff(s) Address In Item B below, place the full name of the defendant in the first blank, his official position in the second blank, and his place of employment in the third blank. Use Item C for the names, positions, and places of employment of any additional defendants. American LegalNet, Inc. www.FormsWorkFlow.com B. Defendant at C. Additional Defendants: is employed as 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 given 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.) American LegalNet, Inc. www.FormsWorkFlow.com V. Relief State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or statutes. Attach no exhibits. VI. Plaintiff's Declaration 1. I understand that I am prohibited from bringing a civil action in forma pauperis if, while I was incarcerated or detained in any facility, I have brought three or more civil actions or appeals in a court of the United States that were dismissed on the grounds that they were frivolous, malicious, or failed to state a claim upon which relief may be granted, unless I am in imminent danger of serious physical injury. 2. I understand that even if I am allowed to proceed in forma pauperis, I am responsible for paying the entire filing fee and any costs assessed by the Court, which, after payment of the partial initial filing fee, shall be deducted from my inmate account by my custodian in installment payments as prescribed by law. 3. I understand that if I am released or transferred, it is my responsibility to keep the Court informed of my whereabouts and failure to do so may result in this action being dismissed with prejudice. 4. I consent to receive orders, notices and judgments by Notice of Electronic Filing. Signed this day of , 20 . Signature of plaintiff(s) American LegalNet, Inc. www.FormsWorkFlow.com