UNITED STATES DISTRICT COURT EASTERN DISTRICT OF TENNESSEE AT ________________________________ ______________________________ ) ______________________________ ) ______________________________ (Enter above the NAME of the plaintiff in this action.) ) v. ) ) _______________________________ ) _______________________________ ) _______________________________ (Enter above the NAME of each defendant in this action.) ) ) COMPLAINT FOR VIOLATION OF CIVIL RIGHTS (42 U.S.C. Section 1983) I. PREVIOUS LAWSUITS A. B. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action or otherwise relating to your imprisonment? YES ( ) NO ( ) 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 the previous lawsuit: Plaintiffs: _______________________________________________________ _______________________________________________________ Defendants: _____________________________________________________ _____________________________________________________ 1 American LegalNet, Inc. www.FormsWorkflow.com 2. COURT: (If federal court, name the district; if state court, name the county): _______________________________________________________________ 3. 4. Name of Judge to whom case was assigned: ____________________________ 5. Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?) _______________________________________________________ 6. Approximate date of filing lawsuit: ___________________________________ 7. II. DOCKET NUMBER: _____________________________________________ Approximate date of disposition: _____________________________________ PLACE OF PRESENT CONFINEMENT: _________________________________________ A. Is there a prisoner grievance procedure in this institution? YES ( ) NO ( ) B. Did you present the facts relating to your complaint in the 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 to B is NO, explain why not. _________________________________ _____________________________________________________________________ E. If there is no prison grievance procedure in the institution, did you complain to the prison authorities? YES ( ) NO ( ) F. If your answer is YES, 1. What steps did you take? ___________________________________________ _______________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com 2. What was the result? ______________________________________________ _______________________________________________________________ III. PARTIES (In item A below, please your name in the first blank and place your present address in the second blank. Do the same for any additional plaintiffs.) A. Name of plaintiff: _______________________________________________________ Present address: ________________________________________________________ Permanent home address: _________________________________________________ Address of nearest relative: _______________________________________________ (In item B below, place the FULL NAME of the defendant in the first blank, his official position in the second blank, and his place of employment in the third blank. Use item C for the additional names, positions, and places of employment of any additional defendants.) B. Defendant: ____________________________________________________________ Official position: _______________________________________________________ Place of employment: ___________________________________________________ C. Additional defendants: __________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 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 extra sheets, if necessary.) ____________________________________________________________________________ ____________________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com V. RELIEF (State BRIEFLY exactly what you want this Court to do for you. Make NO legal arguments. Cite NO cases or statutes.) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ SIGNED THIS _______________ DAY OF ____________________________________, 20______. _____________________________________________ SIGNATURE OF PLAINTIFF 5 American LegalNet, Inc. www.FormsWorkflow.com