INSTRUCTIONS FOR FILING A PRISONER CIVIL RIGHTS COMPLAINT PURSUANT TO 42 U.S.C. § 1983 1. FILL OUT THE FORM: Your complaint must be on the attached form; otherwise it will be returned to you. You may attach additional pages where necessary. You must file a separate complaint for each claim unless the claims are related to the same incident or issue 2. STATE ONLY FACTS. Your complaint must include only facts - not legal arguments or citations. In order to state a claim under §1983, you must state facts which show that the named defendant(s) violated your rights secured by the Constitution. 3. TYPE OR PRINT THE COMPLAINT. Your complaint must be typed or legibly handwritten in pen (not pencil) and written on only one side of the page. 4. PAPER SIZE. All pleadings and other papers submitted for filing must be on letter size 8½” x 11" paper. (not legal size paper). 5. SIGN THE COMPLAINT. The complaint must bear an original signature of the plaintiff and not a copy. The signature does not need to be notarized. 6. LOCATION OF DEFENDANT(S). Your complaint can be filed in this court (the Western District of Louisiana) only if one or more of the named defendants are located within this district. 7. FEES AND COSTS. You must pay a filing fee of $350. If you are unable to pay the entire filing fee and service costs for this action, you may petition the court to proceed as a pauper (“in forma pauperis”). However, even if the court grants your request, you will be required to pay the full filing fee as set forth on the application to proceed in forma pauperis which is attached. 8. PROCEEDING IN FORMA PAUPERIS. If you are proceeding under 28 U.S.C. § 1915, et seq., the court will review your complaint before ordering service of process on the defendants. The review will determine whether the complaint is legally frivolous or malicious, or fails to state a claim upon which relief may be granted, or seeks monetary relief from a defendant who is immune from such relief. See, 28 U.S.C. § 1915(e)(2). Your complaint will also be reviewed to determine whether you should be required to exhaust administrative remedies. See, 42 U.S.C. § 1997e(a). 9. THREE OR MORE SUITS. If you have filed three or more civil actions and/or appeals while incarcerated or detained, and the actions have been dismissed on grounds that they were frivolous, malicious, or failed to state a claim upon which relief may be granted, you will not be permitted to proceed in forma pauperis unless you are under imminent personal danger. See, 28 U.S.C. § 1915(g). 10. WHERE TO MAIL. When the complaint and/or pauper application is completed, inmates who reside in or who are transferred into La. Department of Corrections facilities that are participating in the Electronic Filing Pilot Program, shall provide pleadings to the prison to be scanned and emailed to the court. Inmates at all other facilities shall mail the originals to the Clerk of the United States District Court for the Western District of Louisiana, 300 Fannin Street, Suite 1167, Shreveport, LA 71101-3083. 11. SERVICE OF PROCESS. The Marshal will serve the defendant(s) only if the service costs have been paid, or the court has granted the application to proceed in forma pauperis. You must furnish the Marshal with a correct and complete name and address for each defendant. 12. COPIES. You must pay the Clerk for any copies of your complaint or other court records, even if you are proceeding in forma pauperis. American LegalNet, Inc. www.FormsWorkFlow.com Form to be used by a prisoner filing a civil rights complaint under THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983 UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA Sec.P Full Name of Plaintiff, Prisoner Number Civil Action VS. ___________________________________ Judge __________________________________ Full Name of Defendant ____________________________________ Magistrate Judge COMPLAINT I. Previous Lawsuits A. Have you begun any other lawsuit while incarcerated or detained in any facility? Yes _____ No _____ B. If your answer to the preceding question is yes, provide the following information. 1. State the court(s) where each lawsuit was filed (if federal, identify the District; if state court, identify the county or parish): 2. Name the parties to the previous lawsuit(s): Plaintiffs: Defendants: 3. Docket number(s): 4. Date(s) on which each lawsuit was filed: 5. Disposition and date thereof [For example, was the case dismissed and when? Was it appealed and by whom (plaintiff or defendant)? Is the case still pending?]: 2 American LegalNet, Inc. www.FormsWorkFlow.com C. Have you filed any lawsuit or appeal in any federal district court or appeals court which has been dismissed? Yes _____ No _____ If your answer to the preceding question is yes, state the court(s) which dismissed the case, the civil action number(s), and the reason for dismissal (e.g., frivolity, malice, failure to state a claim, defendants immune from relief sought, etc.). II. A. Name of institution and address of current place of confinement: B. Is there a prison grievance procedure in this institution? Yes _____ No _____ 1. Did you file an administrative grievance based upon the same facts which form the basis of this lawsuit? Yes _____ No _____ If Yes, what is the Administrative Remedy Procedure number? ________________ 2. If you did not file an administrative grievance, explain why you have not done so. 3. If you filed an administrative grievance, answer the following question. What specific steps of the prison procedure did you take and what was the result? (For example, for state prisoners in the custody of the Department of Public Safety and Corrections: did you appeal any adverse decision through to Step 3 of the administrative grievance procedure by appealing to the Secretary of the Louisiana Department of Public Safety and Corrections? For federal prisoners: did you appeal any adverse decision from the warden to the Regional Director for the Federal Bureau of Prisons, or did you make a claim under the Federal Tort Claims Act?) Attach a copy of each prison response and/or decision rendered in the administrative proceeding. III. Parties to Current Lawsuit: 3 American LegalNet, Inc. www.FormsWorkFlow.com A. Name of Plaintiff Address B. Defendant, , is employed as at Defendant, . , is employed as at . , is employed as Defendant, at . Additional defendants IV. Statement of Claim State the FACTS of your case. Specifically describe the involvement and actions of each named defendant. Include the names of all persons involved in the incident(s) or condition(s) giving rise to this lawsuit, and the dates upon which and the places where the incident(s) and/or condition(s) occurred. YOU ARE REQUIRED TO SET FORTH ONLY FACTUAL ALLEGATIONS. YOU ARE NOT REQUIRED TO SET FORTH LEGAL THEORIES OR ARGUMENTS. 4 American LegalNet, Inc. www.FormsWorkFlow.com V. Relief State exactly what you want the court to provide to you or do for you. Make no legal arguments. Cite no cases or statutes. VI. Plaintiff’s Declaration A. I understand that if I am transferred or released, I must apprise the Court of my address, and my failure to do so may result in this complaint being dismissed. B. I understand that I may not proceed without prepayment of costs if I have filed three lawsuits and/or appeals that were dismissed on grounds that the action and/or appeal was frivolous or malicious, or failed to state a claim upon which relief may be granted, unless I am in imminent danger of serious physical injury. C. If I am located in a prison participating in the Electronic Filing Pilot Program, I consent to receive orders, notices and judgments by Notice of Electronic Filing. Signed this _____ day of _______________________, 20____. Prisoner no. (Louisiana Department of Corrections or Federal Bureau of Prisons) Signature of Plaintiff January 2012 updates: pmitchell n:\pro se prisoner forms\1983.prisoner.January2012.wpd American LegalNet, Inc. www.FormsWorkFlow.com