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Pro Se (State Prisoner) Complaint Form. This is a South Carolina form and can be use in District Court Federal.
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UNITED STATES DISTRICT COURT
DISTRICT OF SOUTH CAROLINA
FORMS FOR FILING CASES
PRO SE (Representing Yourself)
State Prisoner
Revised October 3, 2007
Complaint - State Prisoner
Revised October 3, 2007
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IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF SOUTH CAROLINA
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[Enter the full name of the plaintiff in this action]
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Enter above the full name of defendant(s) in this action
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I.
Civil Action No. ___________________________
(to be assigned by Clerk)
COMPLAINT
State Prisoner
PREVIOUS LAWSUITS
A. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action or
otherwise related to your imprisonment?
Yes_______
No_______
B. If your answer to A is Yes, describe the lawsuit in the space below. 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:
Plaintiff: __________________________________________________________________________________
Defendant(s):_______________________________________________________________________________
2. Court:
_____________________________________________________________________________________
(If federal court, name the district; if state court, name the county)
3. Docket Number: _____________________________________________________________________________
4. Name(s) of Judge(s) to whom case was assigned: ___________________________________________________
5. Disposition:
________________________________________________________________________________
(For example, was the case dismissed? Appealed? Pending?)
6. Approximate date of filing lawsuit: ______________________________________________________________
7. Approximate date of disposition: ________________________________________________________________
Complaint - State Prisoner
Revised October 3, 2007
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II.
PLACE OF PRESENT CONFINEMENT
A. Name of Prison/Jail/Institution: ____________________________________________________________________
B. What are the issues that you are attempting to litigate in the above-captioned case? ___________________________
_____________________________________________________________________________________________
C. (1)
(2)
Is there a prisoner grievance procedure in this institution?
Yes_______
No_______
Did you file a grievance concerning the claims you are raising in this matter?
Yes_______
No_______
When____________________________ Grievance Number (if available) ____________________________
D. Have you received a final agency/departmental/institutional answer or determination concerning this matter (i.e., your
grievance)?
Yes_______
No_______
E. When was the final agency/departmental/institutional answer or determination received by you? _________________
If possible, please attach a copy of your grievance and a copy of the highest level decision concerning your grievance
that you have received.
F.
If there is no prison grievance procedures in this institution,
did you complain to prison, jail, or institutional authorities?
Yes_______
No_______
G. If your answer is YES:
1.
What steps did you take?
______________________________________________________________________
2.
What was the result?_________________________________________________________________________
III. PARTIES
In Item A below, place your name, inmate number, and address in the space provided. Do the same for additional plaintiffs,
if any.
A. Name of Plaintiff:________________________________________________
Inmate No.:___________________
Address: ______________________________________________________________________________________
In Item B below, place the full name of the defendant, his official position, and place of employment in the space
provided. Use Item C for additional defendants, if any.
B. Name of Defendant:______________________________________________
Position: _____________________
Place of Employment: ____________________________________________________________________________
C. Additional Defendants (provide the same information for each defendant as listed in Item B above):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Complaint - State Prisoner
Revised October 3, 2007
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IV. STATEMENT OF CLAIM
State here, as briefly as possible, the facts of your case. Describe how each defendant is involved. Include also the
names of other persons involved, dates, and places. 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 an extra sheet if necessary.
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Complaint - State Prisoner
Revised October 3, 2007
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IV. STATEMENT OF CLAIM - continued.
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Complaint - State Prisoner
Revised October 3, 2007
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V.
RELIEF
State briefly and exactly what you want the court to do for you.
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I declare under penalty of perjury that the foregoing is true and correct.
Signed this _________________ day of ___________________________________________________, 20__________.
____________________________________________________________
Signature of Plaintiff
Complaint - State Prisoner
Revised October 3, 2007
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IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF SOUTH CAROLINA
INFORMATION FOR PRISONERS FILING AN APPLICATION TO PROCEED WITHOUT
PREPAYMENT OF FEES AND AFFIDAVIT (FORM AO 240) AND A FINANCIAL CERTIFICATE
WHICH ARE REQUIRED TO PROCEED IN FORMA PAUPERIS IN CIVIL RIGHTS
ACTIONS/BIVENS ACTIONS
Effective April 9, 2006, the costs for filing a lawsuit is $350.00 and must be paid when the complaint is filed.
If you are unable to pay the filing fee, you may file an Application to Proceed without Prepayment of Fees and
Affidavit (Form AO 240) which is a request to proceed in forma pauperis. All prisoners, other than pre-trial
detainees, also must file a completed Financial Certificate.
A. General Information About Form AO 240:
1. The Form AO 240 (form attached) is a request for the court to determine whether you qualify for
proceeding in a case without prepayment of the full filing fee as established in 28 U.S.C. § 1914
(currently $350.00). Payment of the full filing fee is required by 28 U.S.C. § 1915. In order for your
Form AO 240 to be considered by the United States District Court for the District of South Carolina,
it must be typewritten or legibly handwritten. All information must be clearly and concisely written in
the appropriate space on the form. Your original signature must be on the form you submit to the Court.
2. When your Form AO 240 is completed, you should mail THE ORIGINAL Form AO 240 along with
the additional items listed in the Checklist, which is enclosed, to:
Clerk, U.S. District Court
District of South Carolina
901 Richland Street
Columbia, South Carolina 29201
If you are submitting your Form AO 240 and/or Financial Certificate in response to an order of this
Court, you must put your case number on the documents and mail the ORIGINAL documents to the
address provided in the order.
3. It is important to realize that even though a plaintiff may be permitted to proceed without prepayment
of the filing fee, if the plaintiff fails to prevail in the case, costs may be taxed against him or her when
the case is ended, as specified in 28 U.S.C. §§ 1915(f) and 1920; and Flint v. Haynes, 651 F. 2d 970
(4th Cir. 1981).
NOTE TO PRISONER (other than pretrial detainee): Filing the FINANCIAL CERTIFICATE is required under
28 U.S.C. § 1915(a)(2) in order for you to proceed in forma pauperis. THE FORM AO 240 IS NOT
COMPLETE AND WILL NOT BE CONSIDERED BY THE COURT UNLESS THE FINANCIAL
CERTIFICATE HAS BEEN PROPERLY COMPLETED.
B.
General Information About the Financial Certificate:
1. A Financial Certificate (form attached) must accompany your Form AO 240. The Financial Certificate
must be signed by you and be completed and signed by the appropriate officer having authority to
review and calculate financial information in relation to your inmate trust account. If you are detained
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in a county jail, city jail or local detention center, you do not have to submit the Financial
Certificate.
2. If you do not meet the requirements for paying the filing fee in installments, then the full filing fee found
in 28 U.S.C. § 1914 must accompany the civil rights complaint. If you cannot afford to pay the full
filing fee, but you have sufficient funds (as calculated according to the Prison Litigation Reform Act)
to pay an installment payment, then you must pay the first installment of the filing fee, as computed on
the Financial Certificate, at the time you file your complaint.
3. A properly completed financial certificate is required for the court to consider the Form AO 240
submitted by a prisoner in the South Carolina Department of Corrections or Federal Bureau of
Prisons. DO NOT submit your own affidavit instead of the Financial Certificate, or your case may be
delayed. The obligation to pay the filing fee in a case arises out of the filing of a case. See 28 U.S.C.
§ 1915.
4. To obtain a financial certificate disclosing how much money you have credited to your account(s) with
the institution in which you are confined, you must sign your name and write your prisoner number (if
you have one) on the lines provided at the top of the Financial Certificate (form attached). You should
then submit only that page to the division/department that keeps the records of how much money you
have in your account(s). (The name of that division/department varies depending on where you are
being held, for example, "institutional services" - "accounting", etc.)
Someone in that
division/department will complete the remainder of the Financial Certificate and return it to you. It is
then ready to be submitted to the court with the civil rights/Bivens complaint. You must submit the
original Financial Certificate, not a copy.
5. The Financial Certificate must be current and signed by the authorized officer of the penal institution
within six (6) months of its submission to the court. The Form AO 240 with the completed financial
certificate, the accompanying civil rights complaint and all other papers listed on the Checklist must be
mailed to the Clerk's Office TOGETHER.
6. When you receive the completed financial certificate, it will show whether you have sufficient funds
to pay the full filing fee or whether you qualify for proceeding by paying the filing fee in installments.
This determination is based on how much money is currently on deposit in your institutional account(s)
and how much money to which you had access over the past six (6) months. Below is a line-by-line
description of the information provided on the Financial Certificate:
(a)
The first line shows the average monthly deposits to your prison trust account.
(b) The second line shows the average monthly balance in your prison trust account for
the immediate past six (6) full months.
(c)
The third line shows the total amount of money to which you have access in your
institutional account(s) as of the date that the financial certificate was completed.
Money that is not readily accessible is not included in this total; the institution or
agency confining you may have a policy which requires that a certain minimum
balance be maintained, and so the amount shown on the third line would only
include an amount in excess of the required minimum.
(d) The fourth line shows the initial installment payment of the filing fee.
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CHECKLIST
When a civil rights case from a state, local or federal prisoner is received, the Office of the Clerk of Court
shall determine whether the case is in proper form. The term "in proper form" means that the Clerk of Court
has received:
(1) A complaint with your original signature on the appropriate form or in a form substantially
similar;
(2) The full filing fee or an Application to Proceed without Prepayment of Fees and Affidavit
(Form AO 240) requesting to proceed in forma pauperis;
(3) A Financial Certificate form (from all prisoners except pre-trial detainees) completed by the
plaintiff and by an officer or employee of the institution where the plaintiff is confined or
of the prison system in which the plaintiff is confined;
(4) A separate Form USM-285 for each defendant sued if the plaintiff is proceeding in forma
pauperis (Note that the plaintiff must provide information sufficient to identify the
defendant(s) on the Form(s) USM-285. The United States Marshal cannot serve a defendant
that is not properly identified, and defendants that are not served may be dismissed as parties
to a case.);
(5) A separate summons form for each defendant sued or one summons listing all defendants
and their addresses;
If you need additional space on any of the forms, you may submit additional pages. The plaintiff must
use letter-sized paper [8 x 11 inch] and write or type text on one side of a sheet of paper only. Do not write
or type on both sides of any sheet of paper. Do not write to the edge of the paper, but maintain one inch
margins on the top, bottom and sides of each paper submitted.
Note to Inmate: If you are detained in a county jail, city jail, or local detention center, you
do not have to submit the Financial Certificate. You must submit the Form AO 240.
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OAO 240 (Rev. 10/03)
UNITED STATES DISTRICT COURT
District of
APPLICATION TO PROCEED
WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
Plaintiff
V.
CASE NUMBER:
Defendant
I,
declare that I am the (check appropriate box)
G petitioner/plaintiff/movant
G other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1.
Are you currently incarcerated?
G Yes
G No
(If “No,” go to Part 2)
If “Yes,” state the place of your incarceration
Are you employed at the institution?
Do you receive any payment from the institution?
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
2.
Are you currently employed?
G Yes
G No
a.
b.
3.
If the answer is “Yes,” state the amount of your take-home salary or wages and pay period and give the
name and address of your employer.
If the answer is “No,” state the date of your last employment, the amount of your take-home salary or wages
and pay period and the name and address of your last employer.
In the past 12 twelve months have you received any money from any of the following sources?
a.
b.
c.
d.
e.
f.
Business, profession or other self-employment
Rent payments, interest or dividends
Pensions, annuities or life insurance payments
Disability or workers compensation payments
Gifts or inheritances
Any other sources
G
G
G
G
G
G
Yes
Yes
Yes
Yes
Yes
Yes
G
G
G
G
G
G
No
No
No
No
No
No
If the answer to any of the above is “Yes,” describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.
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AO 240 Reverse (Rev. 10/03)
4.
Do you have any cash or checking or savings accounts?
G Yes
G No
If “Yes,” state the total amount.
5.
Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value?
G Yes
G No
If “Yes,” describe the property and state its value.
6.
List the persons who are dependent on you for support, state your relationship to each person and indicate
how much you contribute to their support.
I declare under penalty of perjury that the above information is true and correct.
Date
Signature of Applicant
NOTICE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional officer
showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have
multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each
account.
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FINANCIAL CERTIFICATE
FOR THE DISTRICT OF SOUTH CAROLINA
(for use in § 1983, Bivens, and non-habeas civil actions filed by prisoners)
I request that an authorized officer of the institution in which I am confined, or other person designated
to review financial information in relation to inmate trust funds, complete this Certificate. If I have
insufficient funds in my account that prohibit me from paying the full filing fee required by 28 U.S.C.
§ 1914 (currently $350.00), I will send with my complaint an initial installment payment, required by
28 U.S.C. § 1915, equal to the amount calculated and entered on line four by the authorized officer
signing this form.
I recognize that by filing this case, I am required to pay the full filing fee (or the remaining unpaid
portion of the filing fee by installments if necessary) under 28 U.S.C. § 1915(b) even though I am
requesting to proceed in forma pauperis. I authorize and consent to collection of the filing fee in
accordance with 28 U.S.C. § 1915 until the filing fee is paid in full.
INMATE NAME (PRINTED)
___________________________________
INMATE (PRISONER) NUMBER
_____________________________________
INMATE SIGNATURE
___________________________________
PLACE OF CONFINEMENT
‚
(1) Average monthly deposits
to the inmate’s account..........................$
‚
(2) Average monthly balance
in the inmate’s account
calculated for the prior
six months period. ................................$
‚
(3) Current Balance ....................................$
‚
(4) Initial Installment Payment
(Take 20 percent of the greater
of lines 1 or 2)........................................$
I hereby certify that as of this date, the above financial information is accurate for the above named
inmate.
Authorized Officer’s Signature
__________________________________
Date
Authorized Officer’s Name and Title
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