Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Instructions And Forms For Filing Civil Rights Complaint Form. This is a Wisconsin form and can be use in USDC Western Federal.
Loading PDF...
Tags: Instructions And Forms For Filing Civil Rights Complaint, Wisconsin Federal, USDC Western
Instructions for Filing a Civil Rights Complaint
Under 42 U.S.C. §1983: Prisoner Cases
Note: Pursuant to the Prison Litigation Reform Act (PLRA), 42 U.S.C. §1997e requires
prisoners to exhaust available administrative remedies before initiating a prison condition case
under 42 U.S.C. §1983. Failure to exhaust such remedies will result in dismissal of your case.
Enclosed is a §1983 complaint form, a Petition and Affidavit to Proceed in forma pauperis,
including an Authorization for Release of Institution Account Information, Payment of the Filing Fee
and an information sheet. The filing fee is $350, 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. (See
enclosed information sheet).
Instructions:
1.
You must file with the Clerk of the United States District Court only an ORIGINAL
COMPLAINT. You also should keep a copy of the complaint for your own records.
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 blank pages to the form. Do not use the
back of the form.
5.
If you are unable to prepay the filing fee, you may petition the court for leave to proceed in
forma pauperis by completing and signing, under penalty of perjury, the enclosed petition and
financial affidavit. 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.
When these forms are properly completed, mail them to:
Clerk, United States District Court
United States Courthouse
P. O. Box 432
Madison, Wisconsin 53701-0432
April 07
P\Forms\42USC1983
American LegalNet, Inc.
www.FormsWorkflow.com
Information to Prisoners Seeking Leave to
Proceed with a Civil Action in Federal Court
In Forma Pauperis Pursuant to 28 U.S.C. §1915.
In accordance with the provisions of the Prison Litigation Reform Act (PLRA) which
amended the in forma pauperis (IFP) statute, once a prisoner is permitted to file a civil action, the
prisoner is responsible for the full filing fee of $350, even if the prisoner is granted leave to proceed
IFP.
If you do not have enough money to prepay the full filing fee when your action is filed, you
may request leave to proceed IFP. If you are granted leave to proceed, your complaint will not be
served on the defendants unless the court determines that you have no income and no deposits to
your prison account or until the court has assessed and collected an initial partial filing fee of 20
percent of:
1.
the average monthly deposits to your account for the preceding six-month period, or
2.
the average balance in your account for that same six-month period, whichever sum is
greater.
After you have paid your initial fee, you must make monthly payments to the court equal to
20 percent of your preceding month's income until the $350 filing fee is paid in full.
To proceed with an action, you must complete the enclosed petition and affidavit of
indigency and return it to the court with your ORIGINAL COMPLAINT and a certified copy
of your prison trust account statement showing transactions for the last six months.
Regardless whether some or all of the filing fee has been paid, the court is required to screen
your complaint and to dismiss it 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 liability for money damages. 28
U.S.C. §1915(e).
No action may be brought with respect to prison conditions under 42 U.S.C. §1983 or any
other federal law by a prisoner confined in a correctional institution until any available
administrative remedies are exhausted; that is, until you have sought relief through administrative
channels and been denied such relief. 42 U.S.C. §1997e.
Please note: If you file more than three actions while you are a prisoner that are dismissed
as frivolous or malicious or for failure to state a claim on which relief can be granted, the PLRA
prohibits you from requesting leave to proceed IFP in any other action unless you are in imminent
danger or serious physical injury. 28 U.S.C. §1915.
April 07
P\Forms\42USC1983
American LegalNet, Inc.
www.FormsWorkflow.com
United States District Court
Western District of Wisconsin
___________________________________,
(Full name of plaintiff[s])
___________________________________,
(Prisoner I.D. Number)
Case No.______________________
(Provided by clerk of court)
Plaintiff(s),
v.
___________________________________,
___________________________________,
(Full name of defendant[s])
Defendant(s).
COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983
I.
PLACE OF PRESENT CONFINEMENT (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
NO G
C.
If you have used the grievance process:
1.
2.
D.
Describe what you did and the result, if any.
____________________________________________________________
____________________________________________________________
Is the grievance process completed? ______________________________
If you did not use the grievance process, explain why not.
__________________________________________________________________
__________________________________________________________________
4/07
P\Forms\42USC1983.Complaint
II.
PARTIES
American LegalNet, Inc.
www.FormsWorkflow.com
A.
Your name (Plaintiff) ________________________________________________
B.
Prisoner I.D. Number ________________________________________________
C.
Your address ______________________________________________________
(For additional plaintiffs provide the same information in the same format on a
separate page.)
D.
DEFENDANT (name) _______________________________________________
is employed as _____________________________________________________
at ________________________________________________________________
E.
Additional DEFENDANTS (names and positions):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
III.
__________________________________________________________________
PREVIOUS LAWSUITS
A.
Have you begun other lawsuits in state or federal court relating to the same facts
involved in this action?
YES G
NO G
B.
Have you begun other lawsuits in state or federal court relating to your
imprisonment?
YES G
NO G
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
Complaint Under the Civil Rights Act
Page 4
American LegalNet, Inc.
www.FormsWorkflow.com
county) __________________________________________________
4.
Case number and citation _______________________________________
5.
Basic claim made _____________________________________________
____________________________________________________________
6.
Current status (for example: Was the case dismissed? Was 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.
STATEMENT OF CLAIM
A.
State as briefly as possible the facts of your case. Describe how each named
defendant is involved. Include the names 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 sheets, if necessary. Unrelated separate
claims should be raised in a separate civil action.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Complaint Under the Civil Rights Act
Page 5
American LegalNet, Inc.
www.FormsWorkflow.com
STATEMENT OF CLAIM continued
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
B.
State briefly your legal theory or cite appropriate authority.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Complaint Under the Civil Rights Act
Page 6
American LegalNet, Inc.
www.FormsWorkflow.com
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.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I declare under penalty of perjury that the foregoing is true and correct.
Complaint signed this ___ day of ______________, 20____.
Signature of Plaintiff(s)
____________________________________
(If there are multiple plaintiffs, each must
sign the complaint)
Prisoner I.D. Number(s)
Complaint Under the Civil Rights Act
-7-
Page 7
American LegalNet, Inc.
www.FormsWorkflow.com
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WISCONSIN
______________________________________
Full name of plaintiff(s) or petitioner(s)
Case No. _______________________
(Provided by the clerk of court)
v.
______________________________________
Full name of defendant(s) or respondent(s)
PETITION AND AFFIDAVIT TO PROCEED
WITHOUT PREPAYMENT OF FEES AND/OR COSTS
I, ____________________________________________, declare that I am the plaintiff or petitioner
in the above-named 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. I answer the following questions truthfully and under penalty of
perjury (additional pages may be added, if necessary, to provide complete information):
I. Personal Information
1) Are you currently incarcerated?
G Yes
G No
If “No,” go to question 2. Complete all sections.
If “Yes,” answer questions (a), (b) & (c), skip to Section IV. Complete sections IV and V.
(a)
State the place of your incarceration and provide your prisoner identification number:
_______________________________________
(place)
_____________________________
(number)
GYes
(b)
Are you employed at the institution?
(c)
Do you receive any payment from the institution? GYes
G No
G No
If you are a prisoner, attach a printout of your prison trust account statement showing transactions
for the six-month period immediately preceding the filing of your complaint, motion, or petition and
showing the balance of your release account. Prisoners who are permitted to file in forma pauperis
must pay the full filing fee in installments.
Complaint Under the Civil Rights Act
-8-
Page 8
American LegalNet, Inc.
www.FormsWorkflow.com
(WIWD 01/07)
Personal Information - continued
2) Are you employed?
GYes
G No
3) Are you currently married?
If “Yes,” is your spouse employed?
G Yes
G Yes
G No
G No
4) 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
______________________________
_________________
________
$____________
______________________________
_________________
________
$____________
______________________________
_________________
________
$____________
II. 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?
$ ______________
Provide the name of your employer(s): _______________________________________
State your spouse's total monthly income?
$ ______________
State the amount of money you have received from any other source in the last twelve months
(e.g., rent payments, pension or insurance payments, gifts, inheritance, disability or workers’
compensation payments). Please attach an additional sheet if necessary.
Source of income
Amount
______________________________________________
$ ______________________
______________________________________________
$ ______________________
Complaint Under the Civil Rights Act
-9-
Page 9
American LegalNet, Inc.
www.FormsWorkflow.com
III. 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) What is the total amount of your monthly expenses?
$____________________________
IV. Property - If you are married, your answers must include your spouse's property.
1 ) Do you own a car?
G Yes
G No
If “Yes,” list car(s) below:
Make and Model
Year
Approximate Current Value
_______________________________________________
__________
$___________________________
_______________________________________________
__________
$___________________________
2) Do you own your residence(s)?
G Yes
G No
If “Yes,” state the approximate value(s). $ ____________________
What is the amount of equity (assessed value of residence minus outstanding
mortgage balance) in the residence(s)? $ ____________________
Complaint Under the Civil Rights Act
-10-
Page 10
American LegalNet, Inc.
www.FormsWorkflow.com
IV. Property - continued
3) Do you own any other valuable tangible property, including but not limited to, jewelry, artwork,
G Yes
G No
or antiques?
If “Yes,” identify the property and 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 real estate, stocks, bonds, trusts,
or individual retirement accounts (e.g., IRA, 401 k)?
G Yes
G No
If “Yes,” state the nature of that property and approximate value(s).
____________________________________________________________________________
V. Other Circumstances - Describe any other financial circumstance(s) that you would like the
court to consider when reviewing this petition.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________
Date
Complaint Under the Civil Rights Act
_________________________________________
Signature - Signed Under Penalty of Perjury
-11-
Page 11
American LegalNet, Inc.
www.FormsWorkflow.com
