UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MICHIGAN PrisonerCivilRightsComplaintunder42U.S.C.§1983 Purpose This form is for use by state prisoners filing under 42 U.S.C. § 1983 and federal prisoners filing pursuant to Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics, 403 U.S. 288 (1971). You may file a complaint in the United States District Court for the Eastern District of Michigan if one or more of the named defendants is located within the Eastern District of Michigan or if the cause of action arose in this District. Filling out the form Fill out the attached form and answer each item completely in the space provided. Be sure all answers are typewritten or legibly handwritten. You must file a separate complaint for each claim, unless all the claims are related to the same incident, issue, or defendant. You must provide a complete and accurate list of the name of each defendant, the address for each defendant, and the capacity in which each defendant is being sued. If additional pages are needed, they must be typed or neatly written on 8 ½ x 11" white paper and securely attached to the complaint. You must tell the truth and each plaintiff must sign and date the form. If you make a false statement of a material fact, you may be prosecuted for perjury. Filing Fee For the current filing fee, consult the Fee Schedule on the court's website at www.mied.uscourts.gov. You are obligated to pay the fee even if the court dismisses your complaint or you voluntarily dismiss your complaint. If unable to pay the filing fee, each plaintiff must: Complete an Application to Proceed In Forma Pauperis, Sign the Application to Proceed In Forma Pauperis, and Provide a certified copy of the prison trust fund account statement for the preceding 6 month period. If paying the fee: Checks or money orders must be made payable to "Clerk, U.S. District Court" and sent with the complaint to the address indicated below. If you pay the filing fee when you file your complaint, you will be responsible for serving the defendants. (See Instructions for Preparation and Service of Summons Forms.) Submitting Forms When the complaint is fully completed, mail the original and one copy of the complaint along with all attachments to: Office of the Clerk United States District Court 231 W. Lafayette Boulevard, Fifth Floor Detroit, MI 48226 Failure to comply with all of the instructions will result in unnecessary delays American LegalNet, Inc. www.FormsWorkFlow.com MIED (Rev. 03/11) Prisoner Civil Rights Complaint Official Use Only Case Number Judge Magistrate Judge PRISONER CIVIL RIGHTS COMPLAINT This form is for use by state prisoners filing under 42 U.S.C. § 1983 and federal prisoners filing pursuant to Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics, 403 U.S. 388 (1971). Plaintiff's Information Name Place of Confinement Prisoner No. Street City State Zip Code Are there additional plaintiffs? 9 Yes 9 No If yes, any additional plaintiffs to this action should be listed on a separate 8½" x 11" sheet of paper and securely attached to the back of this complaint. You must provide names, prisoner numbers and addresses for all plaintiffs. Defendant's Information Name Street/P.O. Box City Position State Zip Code Are you suing this defendant in his/her: Are you suing more than one defendant? 9 Personal Capacity 9 Yes 9 Official Capacity 9 No 9 Both Capacities If yes, any additional defendants to this action should be listed on a separate 8½" x 11" sheet of paper and securely attached to the back of this complaint. You must provide their names, positions, current addresses and the capacity (personal, official or both) in which you are suing them. 1 American LegalNet, Inc. www.FormsWorkFlow.com MIED (Rev. 03/11) Prisoner Civil Rights Complaint I. PREVIOUS LAWSUITS Have you filed any other lawsuits in state or federal court relating to your imprisonment? 9 Yes 9 No If "Yes," complete the following section. If "No," proceed to Part II. Please list all prior civil actions or appeals that you have filed in federal court while you have been incarcerated. Docket or Case Number: Name of Court: Parties (Caption or Name of Case): Disposition: Docket or Case Number: Name of Court: Parties (Caption or Name of Case): Disposition: Docket or Case Number: Name of Court: Parties (Caption or Name of Case): Disposition: Any additional civil actions should be listed on a separate sheet of 8½" x11" paper and securely attached to the back of this complaint. 2 American LegalNet, Inc. www.FormsWorkFlow.com MIED (Rev. 03/11) Prisoner Civil Rights Complaint II. STATEMENT OF FACTS State here, as briefly as possible, the facts of your case. Describe how each defendant is involved. Include the names of other people, dates and places involved in the incident. Do not give any legal arguments or cite any cases or statutes. III. STATEMENT OF CLAIMS State what rights under the Constitution, laws, or treaties of the United States have been violated, and be specific. Set forth each claim in a separate paragraph. If you intend to allege several related claims, number and set forth each claim on a separate 8½" x 11" sheet of paper and securely attach the papers to the back of this complaint. IV. RELIEF State briefly and exactly what you want the Court to do for you. 3 American LegalNet, Inc. www.FormsWorkFlow.com MIED (Rev. 03/11) Prisoner Civil Rights Complaint I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed (signed) on (date). Signature of Plaintiff 4 American LegalNet, Inc. www.FormsWorkFlow.com