UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK ________________________________________________________________________x PERSONS IN FEDERAL CUSTODY (Full name and prison ID#) Civil Rights Complaint Pursuant to Title 28 U.S.C. § 1331 (A Bivens Type action) Plaintiff, -against- hmne(s)l, Jury Trial Demand Yes _ No - Defendant(s), ________________________________________________________________________x JURISDICTION 1) , is a citizen of (Plaintiff) (State) who currently resides at (Mailing address of institution) 2) First defendant is a citizen of (Name of defendant) and is employed as (City and State) (Position, Title and Address) at the time the complaint arose, was the defendant acting under the color of federal law? Yes _ No _. If your answer is yes, briefly explain. 3) Second defendant is a citizen of (Name of defendant) and is employed as (City and State) (Position, Title and Address) at the time the complaint arose, was the defendant acting under the color of federal law? Yes _ No _. If your answer is yes, briefly explain. (Use the back of this page to furnish the above information for each additional defendant. lt should be noted: You can bring only a Bivens type action if the individuals were acting under color of federal law; if not, you may still be able to invoke federal jurisdiction under Diversity, Title 28 U.S.C. 0 1391 (a)(Venue)). 4) Jurisdiction is invoked pursuant to Title 28 U.S.C. § 1331 and Bivens v. Six Unknown Named Aoents, 403 U.S. 388, 91 S.Ct. 1999 (1971) because the defendant(s) were acting under the color of federal law. 5) Venue is invoked pursuant to Title 28 U.S.C. 4 1391 (b). (Service of Process must be pursuant to Federal Rules 2001 (C) American LegalNet, Inc. of Civil Procedure 4(d)(l) by service upon the individual of a copy of the summons and complaint personally, or as further described under Rule 4(d)(l)). NATUREOFTHECASE 1) Briefly state the background of your case: CAUSE OF ACTION 1) Allege the following of my constitutional rights, privileges or immunities have been violated; and, the following facts form the basis for my allegations (If necessary, you may attach up to two additional pages (8 % x 11) t o explain any allegations or to list additional supporting facts): (See the Attached Report) Count I. Supporting Facts: (Include all facts you consider important, including names of persons involved, placed and dated. Describe exactly how each defendant is involved. State the facts clearly in your own words without citing legal authority or argument). Count II. Supporting Facts: Count III. Supporting Facts: PROCEDURAL HISTORY 1) Has there been Administrative Relief relating to the claims herein? Yes _ No If yes, explain: 2) Have you begun other lawsuits in this action in state or federal court dealing with the same facts involved in this action or otherwise relating to the claims herein? Yes _ No If yes, describe each lawsuit. (If there is more than one lawsuit, describe each additional lawsuit on another sheet of paper (8 % x 1 l), using the same outline). A) Parties to previous lawsuit: Plaintiff(s): Defendant(s): B) Name of Court and Docket Number: C) Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?): D) Issues raised: 2001 (C) American LegalNet, Inc. 3) I have previously sought informal or formal relief from the appropriate administrative officials regarding the acts complained of herein (Cause of Action). Yes _ No If your answer is yes, briefly describe how relief was sought and the results. If your answer is no, briefly explain why administrative relief was not sought. REQUEST FOR RELIEF I believe I am entitled to the following relief: I HERESY DECLARE, under penalty of perjury, that the foregoing is true and correct. Executed this _ day of ,199_. (Signature of Petitioner) (Mailing Address) (Telephone number) (Signature of attorney, if any) (Attorney address and telephone number) 2001 (C) American LegalNet, Inc.