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Civil Complaint (To Be Used By Prisoner) Form. This is a Pennsylvania form and can be use in USDC Middle Federal.
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Tags: Civil Complaint (To Be Used By Prisoner), Pennsylvania Federal, USDC Middle
FORM TO BE USED BY A PRISONER IN FILING A CIVIL RIGHTS COMPLAINT
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
(1)_________________________________________ :
(Name of Plaintiff)
(Inmate Number)
:
:
_________________________________________ :
(Address)
:
:
(2)_________________________________________ :
(Name of Plaintiff)
(Inmate Number)
:
:
_________________________________________ :
(Address)
:
:
(Each named party must be numbered,
and all names must be printed or typed)
_____________________
(Case Number)
:
:
:
vs.
:
:
(1)_________________________________________ :
:
(2)_________________________________________ :
:
(3)_________________________________________ :
(Names of Defendants)
:
:
(Each named party must be numbered,
and all names must be printed or typed)
TO BE FILED UNDER:
CIVIL COMPLAINT
:
:
42 U.S.C. § 1983 - STATE OFFICIALS
28 U.S.C. § 1331 - FEDERAL OFFICIALS
I.
PREVIOUS LAWSUITS
A.
If you have filed any other lawsuits in federal court while a prisoner, please list the caption and case
number including year, as well as the name of the judicial officer to whom it was assigned:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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II.
EXHAUSTION OF ADMINISTRATIVE REMEDIES
In order to proceed in federal court, you must fully exhaust any available administrative remedies as to
each ground on which you request action.
A.
Is there a prisoner grievance procedure available at your present institution? ____Yes ____No
B.
Have you fully exhausted your available administrative remedies regarding each of your present
claims? ____Yes ____No
C.
If your answer to “B” is Yes:
1. What steps did you take?
2. What was the result?
D.
III.
If your answer to “B” is No, explain why not:
DEFENDANTS
(1) Name of first defendant:
Employed as
at
Mailing address:
(2) Name of second defendant:
Employed as
at
Mailing address:
(3) Name of third defendant:
Employed as
at
Mailing address:
(List any additional defendants, their employment, and addresses on extra sheets if necessary)
IV. STATEMENT OF CLAIM
(State here as briefly as possible the facts of your case. Describe how each defendant is involved, including
dates and places. Do not give any legal arguments or cite any cases or statutes. Attach no more than three
extra sheets if necessary.)
1.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
2.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
V.
RELIEF
(State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or
statutes.)
1.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
I declare under penalty of perjury that the foregoing is true and correct.
Signed this ____________ day of ______________________________, 19____.
______________________________________________________
(Signature of Plaintiff)
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