) ))(Write the full name of the plaintiff in this action. Include prisoner registration number.) v. Case No: to be y Clerk) Plaintiff Requests Trial by Jury ) Yes No ) ) ) ))(Write the full name of each defendant. The caption ) must include the names of all of the parties. ) Fed. R. Civ. P. 10(a). Merely listing one party and ) writing 223et al.224 is insufficient. Attach additional ) sheets if necessary.) ) PRISONER CIVIL RIGHTS COMPLAINT UNDER 42 U.S.C. 247 1983 NOTICE: Federal Rule of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to electronic court files. Under this rule, papers filed with the court should not contain: an individual222s full social security number or full birth date, the full name of a person known to be a minor, or a complete financial account number. A filing may include only: the last four digits of a social security number, the year of an individual222s birth, a minor222s initials, and the last four digits of a financial account number. Except as noted in this form, plaintiff should not send exhibits, affidavits, witness statements, or any other materials to the Clerk222s Office with this complaint. In order for your complaint to be filed, it must be accompanied by the $400.00 filing fee or an application to proceed without prepayment of fees and costs. ) ))) American LegalNet, Inc. www.FormsWorkFlow.com 2 I. The Parties to this Complaint A. The Plaintiff Name: Other names you have used: Prisoner Registration Number: Current Institution:Indicate your prisoner status: Pretrial detainee Convicted and sentenced state prisoner Civilly committed detainee Convicted and sentenced federal prisoner Immigration detainee Other (explain): B. The Defendant(s) To the best of your knowledge, give the information below for each defendant named in the caption of this complaint. Make sure the defendant(s) named below are the same as those listed in the caption of this complaint. Attach additional pages if necessary. For an individual defendant, include the person222s job title, and check whether you are suing the individual in his or her individual capacity, official capacity, or both. Defendant 1 Name: Job or Title: Badge/Shield Number: Employer: Address: Individual Capacity Official Capacity American LegalNet, Inc. www.FormsWorkFlow.com 3 Defendant 2 Name: Job or Title: Badge/Shield Number: Employer: Address: Individual Capacity Official Capacity II.Statement of Claim Type, or neatly print, a short and plain statement of the FACTS that support your claim(s). For every defendant you have named in this complaint, you must state what he or she personally did to harm you. If more than one claim is asserted, number each claim and write a short and plain statement of each claim in a separate paragraph. Do not make legal arguments, or cite court cases or statutes. You may attach additional pages if necessary. Your statement of claim must include all of the following information: 1.What happened to you?2.When did it happen?3.Where did it happen?4.What injuries did you suffer?5.What did each defendant personally do, or fail to do, to harm you? American LegalNet, Inc. www.FormsWorkFlow.com 4 III.Injuries If you sustained injuries related to the events alleged above, describe your injuries and state what medical treatment, if any, you required and did or did not receive. American LegalNet, Inc. www.FormsWorkFlow.com 5 IV.ReliefState briefly and precisely what you want the Court to do for you. Do not make legal arguments. Do not cite any cases or statutes. If you are requesting money damages, include the amounts of any actual damages and/or punitive damages you are claiming. Explain why you believe you are entitled to recover those damages. V. Exhaustion of Administrative Remedies/Administrative Procedures The Prison Litigation Reform Act (223PLRA224) 42 U.S.C. 247 1997e(a), requires that 223[n]o action shall be brought with respect to prison conditions under section 1983 of this title, or any other Federal law, by a prisoner confined in any jail, prison, or other correctional facility until such administrative remedies as are available are exhausted.224 Administrative remedies are also known as grievance procedures. Your case may be dismissed if you have not exhausted your administrative remedies. A. Did your claim(s) arise while you were confined in a jail, prison, or other correctional facility? Yes No If yes, name the jail, prison or other correctional facility where you were confined at the time of the events giving rise to your claim(s): B. Does the jail, prison or other correctional facility where your claim(s) arose have a grievance procedure? Yes No Do not know C. If yes, does the grievance procedure at the jail, prison or other correctional facility where your claim(s) arose cover some or all of your claims? Yes No Do not know American LegalNet, Inc. www.FormsWorkFlow.com 6 If yes, which claim(s)? D. Did you file a grievance in the jail, prison, or other correctional facility where your claim(s) arose concerning the facts relating to this complaint? Yes No If no, did you file a grievance about the events described in this complaint at any other jail, prison, or other correctional facility? Yes No E. If you did file a grievance: 1.Where did you file the grievance? 2.What did you claim in your grievance? (Attach a copy of your grievance, ifavailable) 3.What was the result, if any? (Attach a copy of any written response to yourgrievance, if available) American LegalNet, Inc. www.FormsWorkFlow.com 7 4.What steps, if any, did you take to appeal that decision? Is the grievance processcompleted? If not, explain why not. (Describe all efforts to appeal to the highestlevel of the grievance process.) F. If you did not file a grievance: 1.If there are any reasons why you did not file a grievance, state them here: 2.If you did not file a grievance but you did inform officials of your claim, statewho you informed, when and how, and their response, if any: G. Please set forth any additional information that is relevant to the exhaustion of your administrative remedies. (Note: You may attach as exhibits to this complaint any documents related to the exhaustion of your administrative remedies.) American LegalNet, Inc. www.FormsWorkFlow.com 8 VI.Previous Lawsuits The 223three strikes rule224 bars a prisoner from bringing a civil action or an appeal in federal court without paying the filing fee if that prisoner has 223on three or more prior occasions, while incarcerated or detained in any facility, brought an action or appeal in a court of the United States that was dismissed on the grounds that it is frivolous, malicious, or fails to state a claim upon which relief may be granted, unless the prisoner is under imminent danger of serious physical injury.224 28 U.S.C. 247 1915(g). A. To the best of your knowledge, have you ever had a case dismissed on the basis of this 223three strikes rule224? Yes No If yes, state which court dismissed your case and when it was dismissed. Attach a copy of the court222s order, if possible. Have you filed other lawsuits in state or federal court dealing with the same facts involved in this action? Yes No B. If your answer to A is yes, describe each lawsuit by answering questions 1 through 7 below. (If there is more than one lawsuit, describe the additional lawsuits on another page, using the same format.) 1.Parties to the previous lawsuit Plaintiff Defendant(s) 2.Court (if federal court, name the district; if state court, name the state and county) 3.Docket or case number 4.Name of Judge assigned to your case American LegalNet, Inc. www.FormsWorkFlow.com 9 5.Approximate date of filing lawsuit 6.Is the case still pending? Yes No (If no, give the approximate date of disposition): 7.What was the result of the case? (For example: Was the case dismissed? Wasjudgment entered in your favor? Was the case appealed?) C. Have you filed other lawsuits in state or federal court otherwise relating to the conditions of your imprisonment? Yes No D. If your answer to C is yes, describe each lawsuit by answering questions 1 through 7 below. (If there is more than one lawsuit, describe th