IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIAName and address of Plaintiff: v. Full name, title, and business address of each defendant in this action: 1. 2. Use additional sheets, if necessaryNumber each defendant. Plaintiff brings this action against the above named and identified defendants on the following cause ofaction: I. Where are you now confined? ___________________________________ What sentence are you serving? ________________________________ What court imposed the sentence? ______________________________II. Previous Lawsuits A. Describe any and all lawsuits in which you are a plaintiff which deal with the same facts involved in this action. (If there is more than one lawsuit, describe the additional lawsuits on another piece of paper, using the same outline.) 1. Parties to this previous lawsuit Plaintiffs_____________________________________________________ _______________________________________________________________ Defendants ____________________________________________________ _______________________________________________________________ 2. Court (if federal court, name the district; if state court, name the county) and docket number _______________________________________________________________>>>> 2 _______________________________________________________________ 3. Name of judge to whom case was assigned _______________________ 4. Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?) _______________________________________________________________ _______________________________________________________________ 5. Approximate date of filing lawsuit ____________________________ 6. Approximate date of disposition _______________________________ B. Prior disciplinary proceedings which deal with the same facts involved in this action: Where?_________________________________________________________ When?__________________________________________________________ Result:________________________________________________________ _______________________________________________________________ _______________________________________________________________III. What federal law do you claim was violated? ___________________ _______________________________________________________________ IV. Statement of Claim (State here as briefly as possible the facts of your case. Do not give any legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate paragraph. Use as much space as you need. Attach extra sheet if necessary.) A. Date of event: _______________________________________________ B. Place of event: ______________________________________________ C. Persons involved--name each person and tell what that person did to you: ______________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________>>>> 3 ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________V. Did the incident of which you complain occur in an institution or place of custody in this District? If so, where? _______________________________________________________________ _______________________________________________________________ and answer the following questions: A. Is there a prisoner grievance procedure in this institution? Yes ( ) No ( ) B. Did you present the facts relating to your complaint in the state prisoner grievance procedure? Yes ( ) No ( ) C. If your answer is YES, 1. What steps did you take? ______________________________________ _______________________________________________________________ 2. What was the result? __________________________________________ _______________________________________________________________ D. If your answer is NO, explain why not: ________________________ _______________________________________________________________ E. If there is no prison grievance procedure in the institution, did you complain to prison authorities? Yes ( ) No ( ) F. If your answer is YES, 1. What steps did you take? ______________________________________ _______________________________________________________________ 2. What was the result? __________________________________________ _______________________________________________________________VI. Relief State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or statues. _______________________________________________________________ _______________________________________________________________I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE ANDCORRECT.>>>> 4_______________________________ __________________________________(Date) (Signature of Plaintiff)