Complaint by a Prisoner For Violation of Civil Rights Instructions 1. You may use this form to file an action under 42 U.S.C. § 1983 to challenge a constitutional violation by a person who acts under the authority of a city, county, or state government. 2. You may also use this form to bring a civil rights action against a person who acts under the authority of the federal government. An action for a civil rights violation against a federal defendant is called a "Bivens" action, and is brought under 28 U.S.C. § 1331. 3. Make sure the form is typed or neatly written. 4. You must tell the truth and sign the form. The Court may sanction you if you make a false statement. 5. You need to provide the facts which show the defendant(s) did something to violate your constitutional right. You may submit additional letter-size pages if necessary to describe what happened. You do not need to cite law. 6. The full filing fee is $400.00. If this fee is paid, your complaint will be filed and the Court will order the clerk to serve the complaint on the defendant(s), unless it is clear based on what you allege in the complaint you cannot show a constitutional violation. 7. If you cannot pay the $400.00 filing fee in full when your file your complaint, you may ask to proceed without prepayment by filling out a motion to proceed in forma pauperis. You must submit a certificate signed by an officer at your institution showing the amount of money the institution is holding for you in your trust account and attach a statement of your institution account for the past 6 months. 8. If you are allowed to proceed in forma pauperis, you will not have to pay a fee at the time you file your complaint. You must still, however, pay a $350 filing fee. The $350.00 will be taken out of your institution account in installments, and sent to the Clerk's office. This is required by 28 U.S.C. § 1915. If your motion is granted, the Court will order the Clerk to serve the complaint, unless it is clear based on what you allege in the complaint you cannot show a constitutional violation. 9. After you complete the complaint form, send the original to either address below: Office of the Clerk of Court United States District Court of Wyoming 111 South Wolcott, Room 211 American LegalNet, Inc. www.FormsWorkFlow.com Casper, WY 82601 Office of the Clerk of Court United States District Court of Wyoming 2120 Capitol Avenue, Room 2131 Cheyenne, WY 82001 10. CAUTION: You must exhaust (use up) all the administrative remedies available to you, including appealing your grievances, before you can bring a civil rights action. 11. When you file other documents, send the Clerk an original. (Remember to keep a copy of the complaint and other documents for yourself.) Also send a copy of any document you file (other than the complaint) to each defendant's attorney. Include a certificate of service which shows when you mailed the document to the attorney. State the date you placed the document in the prison mailing system or gave the document to prison officials to mail, and state whether first-class postage has been prepaid. American LegalNet, Inc. www.FormsWorkFlow.com United States District Court District of Wyoming Plaintiff(s) (In the space above enter the full name(s) of the plaintiff(s).If you cannot fit the names of all of the plaintiffs in the space provided, please write "see attached" in the space above and attach an additional sheet of paper with the full list of names), v. (-against-) Case No. _______________ (To be filled out by Clerk's Office only) COMPLAINT (Pro Se Prisoner) Defendant(s) (In the space above enter the full name(s) of the defendant(s). If you cannot fit the names of all of the defendants in the space provided, please write "see attached" in the space above and attach an additional sheet of paper with the full list of names. The names listed in the above caption must be identical to those contained in Section IV. Do not include addresses here.) Jury Demand? 9Yes 9 No Pro Se Civil Rights Complaint page 1 of 13 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE Federal Rule of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to electronic court files. Under this rule, papers filed with the court should not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number. A filing may include only: the last four digits of a social security number; the year of an individual's birth; a minor's initials; and the last four digits of a financial account number. Plaintiff need not send exhibits, affidavits, grievance or witness statements, or any other materials to the Clerk's Office with this complaint. COMPLAINT Indicate below the federal legal basis for your claim, if known. This form is designed primarily for pro se prisoners challenging the constitutionality of their conditions of confinement, claims which are often brought under 42 U.S.C. § 1983 (against state, county, or municipal defendants) or in a "Bivens" action (against federal defendants). 9 9 42 U.S.C. § 1983 (state, county, or municipal defendants) Action under Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971) (federal defendants) PLAINTIFF INFORMATION Name (Last, First, MI) Prisoner ID # Place of Detention Aliases Pro Se Civil Rights Complaint page 2 of 13 American LegalNet, Inc. www.FormsWorkFlow.com Institutional Address County, City State PRISONER STATUS Indicate whether you are a prisoner or other confined person as follows: 9 Pretrial detainee 9 Civilly committed detainee 9 Immigration detainee 9 Convicted and sentenced state prisoner 9 Convicted and sentenced federal prisoner DEFENDANT(S) INFORMATION Please list the following information for each defendant. If the correct information is not provided, it could result in the delay or prevention of service. Make sure that the defendant(s) listed below are identical to those contained in the above caption. Attach additional sheets of paper using the same format for any additional defendants. Defendant 1: Name (Last, First) Current Job Title Current Work Address Zip Code County, City State Zip Code Defendant 2: Name (Last, First) Pro Se Civil Rights Complaint page 3 of 13 American LegalNet, Inc. www.FormsWorkFlow.com Current Job Title Current Work Address County, City State Zip Code Defendant 3: Name (Last, First) Current Job Title Current Work