UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF TEXAS Form To Be Used By A Prisoner in Filing a Complaint Under the Civil Rights Act, 42 U.S.C. § 1983 _________________________________________ Plaintiff's name and ID number _________________________________________ Place of Confinement Case No. (Clerk will assign the number) v. _________________________________________ Defendant's name and address _________________________________________ Defendant's name and address _________________________________________ Defendant ( DO NOT USE "ET AL.") NOTICE: INSTRUCTIONS - READ CAREFULLY Your complaint is subject to dismissal unless it conforms to these instructions and this form. 1. To start an action you must file an original and one copy of your complaint with the court. You should keep a copy of the complaint for your own records. 2. Your complaint must be legibly handwritten, in ink, or typewritten. You, the plaintiff, must sign and declare under penalty of perjury that the facts are correct. If you need additional space, DO NOT USE THE REVERSE SIDE OR BACK SIDE OF ANY PAGE. ATTACH AN ADDITIONAL BLANK PAGE AND WRITE ON IT. 3. You must file a separate complaint for each claim you have unless the various claims are all related to the same incident or issue or are all against the same defendant, Rule 18, Federal Rules of Civil Procedure. Make a short and plain statement of your claim, Rule 8, Federal Rules of Civil Procedure. 4. When these forms are completed, mail the original and one copy to the Clerk of the United States Court for the appropriate District of Texas in the Division where one or more named defendants are located, or where the incident giving rise to your claim for relief occurred. The list labeled as "VENUE LIST" is posted in your unit law library. It is a list of the Texas prison units indicating the appropriate District Court, the Division and an address list of theDivisional Clerks. 1 American LegalNet, Inc. www.FormsWorkflow.com FILING FEE AND IN FORMA PAUPERIS 1. In order for your complaint to be filed, it must be accompanied by the filing fee of $350.00. 2. If you do not have the necessary funds to pay the filing fee in full at this time, you may request permission to proceed in forma pauperis. In this event you must complete the application to proceed in forma pauperis (IFP), setting forth information to establish your inability to prepay the fees and costs or give security therefor. You must also include a current six (6) month history of your Inmate Trust Account. You can acquire the application to proceed IFP and appropriate Inmate Account Certificate from the law library at your prison unit. 3. 28 U.S.C. 1915, as amended by the Prison Litigation Reform Act of 1995 (PLRA), provides, "...if a prisoner brings a civil action or files an appeal in forma pauperis, the prisoner shall be required to pay the full amount of a filing fee." Thus, the Court is required to assess and, when funds exist, collect, the entire filing fee or an initial partial filing fee and monthly installments until the entire amount of the filing fee has been paid by the prisoner. If you submit the application to proceed in forma pauperis , the Court will apply 28 U.S.C. 1915 and, if appropriate, assess and collect the entire filing fee or an initial partial filing fee, then monthly installments from your Inmate Account, until the entire $350 filing fee has been paid. 4. If you intend to seek in forma pauperis status, then do not send your complaint without an Application to Proceed IFP, and the Certificate of Inmate Trust Account. Complete all the essential paperwork before submitting it to the Court. CHANGE OF ADDRESS It is your responsibility to inform the Court of any change of address and its effective date. Such notice should be marked "NOTICE TO THE COURT OF CHANGE OF ADDRESS" and shall not include any motion (s) for any other relief. Failure to file a NOTICE TO THE COURT OF CHANGE OF ADDRESS may result in the dismissal of your complaint pursuant to Rule 41(b), Federal Rules of Civil Procedure. I. PREVIOUS LAWSUITS: A. Have you filed any other lawsuits in state or federal court relating to your imprisonment? ___YES ___NO B. If your answer to "A" is "yes," describe each lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on another piece of paper, giving the same information.) 1. Approximate date of filing lawsuit:____________________________ 2. Parties to previous lawsuit: Plaintiff(s)___________________________________________________ Defendant(s)_________________________________________________ 3. Court: (If federal, name the district; if state, name the county.) __________________________ 4. Docket Number:________________________________________________ 5. Name of judge to whom case was assigned:___________________________ 6. Disposition: (Was the case dismissed, appealed, still pending?) ______________________________________________________________ 7. Approximate date of disposition:___________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com II. PLACE OF PRESENT CONFINEMENT:___________________________________________ III. EXHAUSTION OF GRIEVANCE PROCEDURES: Have you exhausted both steps of the grievance procedure in this institution? ___YES ___NO Attach a copy of the Step 2 grievance with the response supplied by the prison system. IV. PARTIES TO THIS SUIT: A. Name and address of plaintiff:___________________________________________ ___________________________________________________________________ ___________________________________________________________________ B. Full name of each defendant, his official position, his place of employment, and his full mailing address. Defendant #1: ______________________________________________________ ___________________________________________________________________ Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. Defendant #2:________________________________________________________ ___________________________________________________________________ Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. Defendant #3:________________________________________________________ ___________________________________________________________________ Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. Defendant #4:________________________________________________________ ___________________________________________________________________ Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. Defendant #5:________________________________________________________ ____________________________________________________________________ Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. 3 American LegalNet, Inc. www.FormsWorkflow.com V. STATEMENT OF CLAIM: State here in a short and plain statement the facts of your case, that is, what happened, where did it happen, when did it happen, and who was involved. Describe how each defendant is involved. You need 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. Attach extra pages if necessary, but remember that the complaint must be stated briefly and concisely. IF YOU VIOLATE THIS RULE, THE COURT MAY STRIKE YOUR COMPLAINT. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ VI. RELIEF: State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or statutes. ______________________________________________________________________________________ ______________________________________________________________________________________ VII. GENERAL BACKGROUND INFORMATION: A. State, in complete form, all names you have ever used or been known by including any and all aliases: _______________________________________________________________________________________ B. List all TDCJ-ID identification numbers you have ever been assigned and all other state or federal prison or FBI numbers ever assigned to you, if known to you. _______________________________________________________________________________________ VIII. SANCTIONS: A. Have you been sanctioned by any court as a result of any lawsuit you have filed? ____YES ____NO B. If your answer is "yes", give the following information for every lawsuit in which sanctions were imposed. (If more than one, use another piece of paper and answer the same questions.) 1. Court that imposed sanctions (if federal, give the district and division): 2. Case Number: 3. Approximate date sanctions were imposed: 4. Have the sanctions been lifted or otherwise satisfied? ____YES____NO 4 American LegalNet, Inc. www.FormsWorkflow.com C. Has any court ever warned or notified you that sanctions could be imposed? D. If your answer is "yes", give the following information for every lawsuit in which warning was imposed. (If more than one, use another piece of paper and answer the same questions.) _____YES____NO 1. Court that imposed warning (if federal, give the district and division): __________________________ 2. Case Number: 3. Approximate date warnings were imposed: Executed on: ____________ DATE ____________________________________ ____________________________________ (Signature of plaintiff) PLAINTIFF'S DECLARATIONS 1. I declare under penalty of perjury all facts presented in this complaint and attachments thereto are true and correct. 2. I understand if I am released or transferred, it is my responsibility to keep the Court informed of my current mailing address and failure to do so may result in the dismissal of this lawsuit. 3. I understand that I must exhaust all available administrative remedies prior to filing this lawsuit. 4. I understand I am prohibited from bringing an in forma pauperis lawsuit if I have brought three or more civil actions in a Court of the United States while incarcerated or detained in any facility, which lawsuits were dismissed on the ground they were frivolous, malicious, or failed to state a claim upon which relief may be granted, unless I am under imminent danger of serious physical injury. 5. I understand even if I am allowed to proceed without prepayment of costs, I am responsible for the entire $350 filing fee and costs assessed by the Court, which shall be deducted in accordance with the law from my inmate account by my custodian until the filing fee is paid. Signed this ____________________ day of ____________________, __________. (Day) (month) (year) ____________________________________ ____________________________________ (Signature of plaintiff) WARNING: The Plaintiff is hereby advised any false or deliberately misleading information provided in response to the following questions will result in the imposition of sanctions. The sanctions the Court may impose include, but are not limited to monetary sanctions and/or the dismissal of this action with prejudice. 5 American LegalNet, Inc. www.FormsWorkflow.com