INSTRUCTIONS FOR FILING A CIVIL RIGHTS COMPLAINT UNDER 42 U.S.C. § 1983: PRISONER CASES Enclosed is a § 1983 complaint form, a Petition and Affidavit to Proceed in forma pauperis, including an Authorization for Release of Institutional Account Information and Payment of the Filing Fee, an information sheet, and a Notice of Lawsuit and Request for W aiver of Service of Summons form. The filing fee is $350.00 which must be paid at the time the action is filed. If you are unable to pay the fee, you may petition the court for leave to proceed in forma pauperis. Instructions: 1. You must file with the Clerk of the United States District Court an original complaint and one copy for each defendant that you sue. You also should keep a copy of the complaint for your own records. All copies of the complaint must be identical to the original. 2. Your complaint must be legibly handwritten or typed. The complaint must be signed by each plaintiff and should include the prisoner identification number of each plaintiff. The complaint need not be notarized. Answer each question to the best of your knowledge and belief. Be concise. 3. Provide facts supporting your claims. You must explain what each defendant did to violate your federal rights. Include the relief you are requesting from the court. 4. Please try to keep your complaint to the space provided. However, if you need additional space to answer a question or state your claim, attach additional pages to the form. Do not use the back of the form. 5. If you are unable to pay the filing fee, you may petition the court for leave to proceed in forma pauperis by completing and signing, under penalty of perjury, the attached petition and affidavit to proceed without prepayment of fees and/or costs. This need not be notarized. Each plaintiff who seeks to file in forma pauperis must complete a petition and affidavit. 6. You must also file a certified copy of your trust fund account statement for the six month period immediately preceding the filing of the complaint. 7. W hen these forms are properly completed, mail them to: Clerk, United States District Court United States Courthouse, Rm. 362 517 E. W isconsin Avenue Milwaukee, W isconsin 53202 i American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT EASTERN DISTRICT OF WISCONSIN , (Full N ame o f each P laintiff) Plaintiff(s), Case No. (S upplied by C lerk) v. , (Full N ame o f each D efendant) Defendant(s). COM PLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983 I. PLACE OF PRESENT CONFINEM ENT (Provide full address) YES G NO G A. Is there a grievance procedure in your prison/jail? B. Have you filed a grievance concerning the facts relating to this complaint? YES G II. NO G PARTIES A. Your name (Plaintiff) B. Prisoner I.D. Number C. Social Security Number (Last Four Digits Only) D. Your Address (City & State) (For additional plaintiffs provide the same information in the same format on a separate page.) American LegalNet, Inc. www.FormsWorkFlow.com E. DEFENDANT (name) is employed as at F. III. Additional DEFENDANTS (name, position, and place of employment): PREVIOUS LAWSUITS A. Have you begun other lawsuits in state or federal court relating to the same facts involved in this action? G YES G NO B. Have you begun other lawsuits in state or federal court relating to your imprisonment?G YES G NO C. If your answer is YES to either of the above questions, provide the following requested information. 1. Parties to the previous lawsuit Plaintiff(s): Defendant(s): 2. Date filed 3. Court where case filed (if federal court, name district: if state court, name the county) 4. Case number and citation 5. Nature of claim -2American LegalNet, Inc. www.FormsWorkFlow.com 6. Current status (for example: W as the case dismissed? W as it appealed? Is it still pending?) 7. If resolved, date of disposition 8. If resolved, state whether for (plaintiff or defendant) (For additional cases, provide the above information in the same format on a separate page.) IV. STATEM ENT OF CLAIM A. State as briefly as possible the facts of your case. Describe how each named defendant is involved. Include the name of other persons involved, dates, and places. Describe specifically the injuries incurred. Do not give legal arguments or cite cases or statutes. You may do that in Item "B" below. If you allege related claims, number and set forth each claim in a separate paragraph. Use as much space as you need to state the facts. Attach extra pages, if necessary. Unrelated separate claims should be raised in a separate civil action. STATEM ENT OF CLAIM continued -3American LegalNet, Inc. www.FormsWorkFlow.com B. State briefly your legal theory or cite appropriate authority. V. RELIEF YOU REQUEST State briefly and exactly what you want the court to do for you. Make no legal arguments. Do not use this space to state the facts of your claim. Use it only to request remedies for the injuries you complain about. -4American LegalNet, Inc. www.FormsWorkFlow.com I declare under penalty of perjury that the foregoing is true and correct. Complaint signed this day of , . Signature of Plaintiff(s) (If there are multiple plaintiffs, each must sign the complaint) Prisoner I.D. Number(s) -5American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Petition and Affidavit to Proceed Without Prepayment of Fees and/or Costs Before District Court or on Appeal – Read Carefully 1. Purpose of Form - This form may be used to establish indigency for the purpose of (1) obtaining a waiver of the applicable filing fee for your action; (2) obtaining a waiver of the applicable fee for filing an appeal; (3) establishing financial eligibility for the appointment of counsel; or (4) waiving of other fees, such as fees for transcripts or subpoenas. 2. Signed Under Penalty Of Perjury - To submit your petition and affidavit, it must be signed. Your signature indicates that the Petition and Affidavit is signed "under penalty of perjury.” This means that any false statement of a material fact presented in your petition may serve as a basis for prosecution and conviction for perjury. Your signature does not have to be witnessed by a notary public. 3. If You Are A Non-Prisoner Bringing a Civil Action, You Are Advised - The filing fee for a civil action (other than a petition for habeas corpus relief pursuant to 28 U.S.C. § 2241, § 2254 or a motion pursuant to 28 U.S.C. § 2255) is $350.00. If you are bringing a petition for habeas corpus relief pursuant to 28 U.S.C. § 2241, § 2254 or a motion pursuant to 28 U.S.C. § 2255, refer to number five of these instructions. If you have the money to pay the filing fee, you should send a cashier's check or money order for $350.00, payable to “Clerk, United States District Court,” with your complaint. If you do not have enough money to pay the full filing fee at the time your action is filed, you may petition the court to proceed without prepayment of fees and costs by using the attached form. Upon receipt of your complaint and petition, the court will screen the complaint. The court shall dismiss your complaint if (1) your allegation of poverty is untrue; (2) the action is frivolous or malicious; (3) your complaint does not state a claim on which relief can be granted; or (4) you sue a defendant for money damages and that defendant is immune from such relief. 28 U.S.C. § 1915(e). If your petition is granted, you will proceed in forma pauperis (IFP). This means that the $350.00 filing fee will be waived. If your petition is denied because you are financially ineligible to proceed IFP, you will be required to pay the full $350.00 filing fee. Your suit will not proceed unless the fee is paid in full. 4. If You Are a Prisoner Who Is Bringing a Civil Rights or Other Civil Action, You Are Advised In accordance with the provisions of the Prison Litigation Reform Act (PLRA), prisoners are obligated to pay the full filing fee of $350.00 for a civil action. 28 U.S.C. § 1915(b)(1). If you have the money to pay the filing fee, you should send a cashier's check or money order for $350.00, payable to "Clerk, United States District Court," with your complaint. If you do not have enough money to pay the full filing fee at the time your action is filed, you may petition the court to proceed without prepayment of fees and costs by using the attached form. If your petition is granted, you will pay the $350.00 filing fee in installments, beginning with an initial partial filing fee. The initial partial filing fee will be calculated from a certified copy of your prison trust account statement that shows transactions for the last six months. The trust account statement must be filed in support of your petition. (Statements are required for any prison or jail trust accounts you have had over the prior Petition and Affidavit To Proc eed W ithout Prepay ment of Fees And/Or Costs J anuary 2011 American LegalNet, Inc. www.FormsWorkFlow.com Instructions - continued six months). Failure to do so may result in the petition being denied. The initial partial filing fee will be 20 percent of: (A) the average monthly deposits to your account for the immediately preceding six-month period, or (B) the average monthly balance in your account for that same six-month period, whichever amount is greater. You will be required to pay the initial partial filing fee out of your account if funds exist. 28 U.S.C. § 1915(b)(1). After the initial partial filing fee is paid, monthly installments equal to 20 percent of your preceding month's income will be withdrawn from your account and forwarded to the court. However, if the amount in your account is less than $10.00, no installment will be withdrawn. W ithdrawals will routinely occur until the full $350.00 filing fee is paid. 28 U.S.C. § 1915(b)(2). Regardless of whether some or all of the filing fee has been paid, the court is required to screen your complaint. The court shall dismiss the complaint if (1) your allegation of poverty is untrue - i.e., if your petition and affidavit to proceed without prepayment of fees contains false information; (2) the action is frivolous or malicious; (3) your complaint does not state a claim on which relief can be granted; or (4) you sue a defendant for money damages and that defendant is immune from such relief. 28 U.S.C. § 1915(e)(2); 28 U.S.C. § 1915A. W ith respect to claims based on prison conditions, no action may be brought under 42 U.S.C. § 1983 or any other federal law by a prisoner confined in a correctional institution until the available administrative remedies are exhausted. 42 U.S.C. § 1997e. Note: If, while you are a prisoner, you file three or more actions or appeals which are dismissed as frivolous or malicious or for failure to state a claim upon which relief may be granted, then you will be prohibited from bringing any other actions IFP unless you are in imminent danger of serious physical injury. 28 U.S.C. § 1915(g). Multiple Prisoners Bringing a Single Action If multiple prisoners are bringing a single action and not seeking leave to proceed IFP (i.e., the full filing fee is paid at the time the complaint is filed), then one filing fee ($350.00) is required per action. However, if multiple prisoners are bringing a single action and seeking leave to proceed IFP, then one filing fee ($350.00) is required per prisoner. Each prisoner must submit an individual petition and affidavit to proceed without prepayment of fees and a trust account statement showing transactions for the last six months. 5. If You Are a Prisoner or Pretrial Detainee Who Is Filing a Petition Pursuant to 28 U.S.C. § 2241, § 2254 or a M otion Pursuant to § 2255, You Are Advised - The filing fee for a § 2241 or § 2254 petition is $5.00. If you have the money to pay the filing fee, you should send a cashier's check or money order for $5.00, payable to “Clerk, United States District Court," with your complaint. There is no filing fee for a motion to vacate, set aside, or correct sentence pursuant to § 2255. Petition and Affidavit To Proc eed W ithout Prepay ment of Fees And/Or Costs J anuary 2011 ii American LegalNet, Inc. www.FormsWorkFlow.com Instructions - continued Note: Regardless of whether you are filing a petition pursuant to § 2241, § 2254, or a motion pursuant to § 2255, you must have an authorized officer attach a printout of your prison trust account activity statement for the six months prior to the filing of your petition. 6. If You Are a Non-prisoner Filing an Appeal From a District Court Judgment or Decision, You Are Advised - The current fee for filing an appeal is $455.00. If you have the money to pay the appellate filing fee, you should send a cashier’s check or money order for $455.00, payable to "Clerk, United States District Court,” with your notice of appeal. If you do not have enough money to pay the full filing fee at the time your appeal is filed and you were permitted to proceed IFP, you may proceed on appeal without further authorization unless the district court certifies that your appeal is not taken in good faith or you are otherwise not entitled to proceed IFP. If you do not have enough money to pay the full filing fee at the time your appeal is filed and you were not previously permitted to proceed IFP, you may petition the court to proceed without prepayment of fees and costs by using the attached form. Upon receipt of petition, the court will review your petition. The court shall deny your IFP petition if it determines that (1) your allegation of poverty is untrue; or (2) the appeal is frivolous or malicious or not taken in good faith. 28 U.S.C. § 1915(a)(3) & (e)(2); 28 U.S.C. § 1915A; Fed. R. App. P. 24. If your petition is granted, you will proceed IFP. This means that the $455.00 appeal filing fee will be waived. If your petition is denied because you are financially ineligible to proceed IFP, you will be required to pay the full $455.00 appeal filing fee. Your suit will not proceed unless the fee is paid in full. 7. If You Are a Prisoner Filing an Appeal in a Civil Rights or Other Civil Action, You Are Advised In accordance with the provisions of the PLRA, prisoners are obligated to pay the full filing fee of $455.00 for a civil appeal. 28 U.S.C. § 1915(b)(1). If you have the money to pay the filing fee, you should send a cashier’s check or money order for $455.00, payable to "Clerk, United States District Court" with your notice of appeal. If you do not have enough money to pay the full filing fee at the time your appeal is filed, you may petition the district court to proceed without prepayment of fees and costs by using the attached form. If your petition is granted, you will pay the $455.00 filing fee in installments, beginning with an initial partial appeal filing fee. The initial partial appeal filing fee will be calculated from a certified copy of your prison trust account statement that shows transactions for the last six months. The trust account statement must be filed in support of your petition. (Statements are required for any prison or jail trust accounts you have had over the prior six months). Failure to do so may result in the petition being denied. Petition and Affidavit To Proc eed W ithout Prepay ment of Fees And/Or Costs J anuary 2011 iii American LegalNet, Inc. www.FormsWorkFlow.com Instructions - continued The initial partial appeal filing fee will be 20 percent of: (A) the average monthly deposits to your account for the immediately preceding six-month period, or (B) the average monthly balance in your account for that same six-month period, whichever amount is greater. You will be required to pay the initial partial appeal filing fee out of your account if funds exist. 28 U.S.C. § 1915(b)(1). After the initial partial appeal filing fee is paid, monthly installments equal to 20 percent of your preceding month's income will be withdrawn from your account and forwarded to the court. However, if the amount in your account is less than $10.00, no installment will be withdrawn. W ithdrawals will routinely occur until the full $455.00 appeal filing fee is paid. 28 U.S.C. § 1915(b)(2). Regardless of whether some or all of the appeal filing fee has been paid, the court shall dismiss the appeal if (1) your allegation of poverty is untrue; or (2) the action is frivolous or malicious or not taken in good faith. 28 U.S.C. § 1915(a)(3) & (e)(2). Note: If, while you are a prisoner, you file three or more actions or appeals which are dismissed as frivolous or malicious or for failure to state a claim upon which relief may be granted, then you will be prohibited from bringing any other actions or appeals IFP unless you are under imminent danger of serious physical injury. 28 U.S.C. § 1915(g). Multiple Prisoners Bringing a Single Appeal If multiple prisoners are bringing a single appeal and not seeking leave to proceed IFP (i.e., the full appeal filing fee is paid at the time the notice of appeal is filed), then one filing fee ($455.00) for the appeal is required. However, if multiple prisoners are bringing a single appeal and seeking leave to proceed IFP on appeal, then one filing fee ($455.00) is required per prisoner. Each prisoner must submit an individual petition and affidavit to proceed without prepayment of fees and a trust account statement showing transactions for the last six months. 8. If You Are a Prisoner or Pretrial Detainee Filing an Appeal in Action on a Petition Pursuant to 28 U.S.C. § 2241, § 2254 or a M otion Pursuant to § 2255, You Are Advised - You should refer to number six of these instructions. IN ADDITION: Regardless of whether you are filing an appeal from action on a petition pursuant to § 2241, § 2254, or a motion pursuant to § 2255, you must have an authorized officer attach a printout of your prison trust account activity statement for the six months prior to the filing of your appeal. Petition and Affidavit To Proc eed W ithout Prepay ment of Fees And/Or Costs J anuary 2011 iv American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT EASTERN DISTRICT OF WISCONSIN In the Case of Docket No. ____________________ v. (To be S upplied by C lerk) PETITION AND AFFIDAVIT TO PROCEED WITHOUT PREPAYMENT OF FEES AND/OR COSTS I, ________________________________________________________, declare that I am the (print your full name) G Petitioner G Plaintiff G Movant 9 Appellant G Other______________________________ in the above-entitled action. In support of my request to proceed in forma pauperis, I declare that I am unable to pay the fees and/or costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion/appeal. In support of this petition, I answer the following questions truthfully and under penalty of perjury: (Additional pages may be added, if necessary, to provide complete information.) Appeals If you are filing an appeal from a district court’s judgment/decision, state the issues that you intend to appeal: Petition and Affidavit To Proceed Without Prepayment of Fees And/Or Costs January 2011 -1- American LegalNet, Inc. www.FormsWorkFlow.com Personal Information 1) G Yes Are you employed? G No If no, give the month and year when you were last employed and state the amount of that monthly income. $ (month and year) 2) G Yes Are you currently incarcerated? G No If yes, state the place of your incarceration and provide your prisoner identification number: (place) (number) In addition, if you are a prisoner, you must have an authorized officer attach a printout of your prison trust account statement showing transactions for the six-month period immediately preceding the filing of your complaint, motion, petition or appeal and showing the balance of your release account. You must also complete the attached “Authorization for Release of Institutional Account Information and Payment of the Filing Fee.” 4) Are you currently married? G Yes G No If yes, is your spouse employed? 3) G Yes G No Do you have any legal dependents (children/adults) whom you are responsible for supporting? G Yes G No If yes, list them below: First and Last Initials (For Minor Children Only) or Name Relationship To You Age Amount of Support Provided Per Month __________________________________ ____________________ ________ $_____________ __________________________________ ____________________ ________ $_____________ __________________________________ ____________________ ________ $_____________ Property – If you are married, your answers must include your spouse’s property. 1) Do you own a car? G Yes G No Petition and Affidavit To Proc eed W ithout Prepay ment of Fees And/Or Costs J anuary 2011 -2- American LegalNet, Inc. www.FormsWorkFlow.com Property -continued If yes, list car(s) below: Model and Make Year _____________________________________________ ________ $______________________ _____________________________________________ ________ $______________________ _____________________________________________ ________ $______________________ 2) Do you own your residence(s)? G Yes If yes, state the approximate value(s). 3) Approximate Current Value G No $_____________________ Do you own any other valuable tangible property, including but not limited to, jewelry, artwork, or antiques? G Yes G No If yes, identify the property and its approximate value(s). Property Approximate Value __________________________________________ $______________________ __________________________________________ $______________________ __________________________________________ $______________________ 4) Do you have any cash or checking, savings, or other similar accounts? G Yes G No If yes, state the total amount of such sums. $________________ 5) Do you own any intangible property, including but not limited to stocks, bonds, trusts, or individual retirement accounts (e.g., IRA, 401k)? G Yes G No If yes, state the nature of that property and the approximate value(s). Petition and Affidavit To Proc eed W ithout Prepay ment of Fees And/Or Costs J anuary 2011 -3- American LegalNet, Inc. www.FormsWorkFlow.com Income – If you are married, your answers must include your spouse’s income. (When calculating income, you must include any salary, child support, public assistance, unemployment compensation, disability payments, life insurance payments, pensions, annuities, workers’ compensation, stock dividends and interest, gifts, and inheritance, or other incoming monies.) State your total monthly income: $________________ State your spouse’s total monthly income: $________________ Expenses – If you are married and/or have dependents, your expenses should also include your household’s expenses. (When calculating household expenses, you may include groceries, clothing, medical costs, utilities which are not included in your rental payments, transportation, and insurance.) 1) Identify the following amounts that you pay per month: G Rent or G Mortgage $________________ Car payment(s) $________________ Alimony and/or court-ordered child support $________________ Credit card payment(s) $ 2) Do you have any other monthly expenses that you have not already identified? G Yes G No If yes, list them below: Expense Amount __________________________________________________________ $___________________ __________________________________________________________ $___________________ __________________________________________________________ $___________________ __________________________________________________________ $___________________ 3) W hat is the total amount of your monthly expenses? Petition and Affidavit To Proc eed W ithout Prepay ment of Fees And/Or Costs $________________ J anuary 2011 -4- American LegalNet, Inc. www.FormsWorkFlow.com Other Circumstances – Describe any other financial circumstance(s) that you would like the court to consider when reviewing this petition. Date Signature – Signed Under Penalty of Perjury Petition and Affidavit To Proceed Without Prepayment of Fees And/Or Costs January 2011 -5- American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT EASTERN DISTRICT OF WISCONSIN In the Case of Docket No. ____________________ v. (To be S upplied by C lerk) AUTHORIZ ATION FOR RELEASE OF INSTITUTIONAL ACCOUNT INFORM ATION AND PAYM ENT OF THE FILING FEE Instructions Use this Authorization: If you are a prisoner filing a civil rights or other civil action, or an appeal, complete this authorization. Do not use this Authorization: 1. If you are not a prisoner 2. If you are a prisoner or are “in custody" and are petitioning the court for a writ of habeas corpus under 28 U.S.C. § 2254 or 28 U.S.C. § 2241. 3. If you are a prisoner filing a motion to vacate, set aside, or correct your sentence under 28 U.S.C. § 2255. * * * * * * * I, (Name of Plaintiff) (Prison Identification Number) I authorize the clerk of court to obtain from the agency having custody of my person, information about my prison trust account, including balances, deposits, and withdrawals until the filing fee is paid. I understand that, when sufficient funds exist in my prison trust account, I will be required to pay an initial partial filing fee equal to 20 percent of the greater of: (A) the average monthly deposits to my account for the six-month period immediately preceding the filing of my complaint or notice of appeal, or (B) the average monthly balance in my account for the six-month period immediately preceding the filing of the complaint or notice of appeal. I understand and hereby authorize that, after payment of the initial partial filing fee, monthly payments will be forwarded to the clerk of court equal to 20 percent of the preceding month's income credited to my account. I hereby authorize the agency or facility having custody of my person to withdraw funds from my prison trust account and forward such payments from my account to the clerk of court each time the amount in the account exceeds $10.00, until the filing fee is paid as set forth in 28 U.S.C. § 1915(b)(2). (Signature of Plaintiff) (Date) NOTE: A CERTIFIED COPY OF YOUR PRISON TRUST ACCOUNT STATEMENT SHOWING TRANSACTIONS FOR THE SIX-MONTH PERIOD IMMEDIATELY PRECEDING THE FILING OF YOUR COMPLAINT MUST ACCOMPANY THIS PETITION AND AFFIDAVIT. (Statements are required for any prison or jail trust accounts you have had over the prior six months.) Petition and Affidavit To Proc eed W ithout Prepay ment of Fees And/Or Costs J anuary 2011 -6- American LegalNet, Inc. www.FormsWorkFlow.com