Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_15-cv-00594/USCOURTS-azd-2_15-cv-00594-0/pdf.json

Nature of Suit Code: 555
Nature of Suit: Prisoner - Prison Condition
Cause of Action: 42:1983 Prisoner Civil Rights

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MDR 

WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Cedric Ross Jordan, 

Plaintiff, 

v. 

J. Caffey, 

Defendant. 

No. CV 15-0594-PHX-DGC (MEA) 

ORDER 

On April 2, 2015, Plaintiff Cedric Ross Jordan, who is confined in the Arizona 

State Prison Complex-Lewis in Buckeye, Arizona, filed a pro se civil rights Complaint 

pursuant to 42 U.S.C. § 1983 (Doc. 1) and an Application to Proceed In Forma 

Pauperis (Doc. 2). On April 22, 2015, he filed a Motion for Appointed Counsel (Doc. 7). 

The Court will grant the Application to Proceed, dismiss the Complaint with leave to 

amend, and deny without prejudice the Motion for Appointed Counsel. 

I. Application to Proceed In Forma Pauperis and Filing Fee

 Plaintiff’s Application to Proceed In Forma Pauperis will be granted. 28 U.S.C. 

§ 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. § 1915(b)(1). 

The Court will assess an initial partial filing fee of $1.80. The remainder of the fee will 

be collected monthly in payments of 20% of the previous month’s income credited to 

Plaintiff’s trust account each time the amount in the account exceeds $10.00. 28 U.S.C. 

§ 1915(b)(2). The Court will enter a separate Order requiring the appropriate government 

agency to collect and forward the fees according to the statutory formula. 

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II. Statutory Screening of Prisoner Complaints

 The Court is required to screen complaints brought by prisoners seeking relief 

against a governmental entity or an officer or an employee of a governmental entity. 28 

U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff 

has raised claims that are legally frivolous or malicious, that fail to state a claim upon 

which relief may be granted, or that seek monetary relief from a defendant who is 

immune from such relief. 28 U.S.C. § 1915A(b)(1)–(2). 

 A pleading must contain a “short and plain statement of the claim showing that the 

pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 

does not demand detailed factual allegations, “it demands more than an unadorned, thedefendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678 

(2009). “Threadbare recitals of the elements of a cause of action, supported by mere 

conclusory statements, do not suffice.” Id. 

 “[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a 

claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly, 

550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual 

content that allows the court to draw the reasonable inference that the defendant is liable 

for the misconduct alleged.” Id. “Determining whether a complaint states a plausible 

claim for relief [is] . . . a context-specific task that requires the reviewing court to draw 

on its judicial experience and common sense.” Id. at 679. Thus, although a plaintiff’s 

specific factual allegations may be consistent with a constitutional claim, a court must 

assess whether there are other “more likely explanations” for a defendant’s conduct. Id.

at 681. 

 But as the United States Court of Appeals for the Ninth Circuit has instructed, 

courts must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 

342 (9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less 

stringent standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. 

Pardus, 551 U.S. 89, 94 (2007) (per curiam)). 

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 If the Court determines that a pleading could be cured by the allegation of other 

facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal 

of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) (en banc). 

Plaintiff’s Complaint will be dismissed for failure to state a claim, but because it may 

possibly be amended to state a claim, the Court will dismiss it with leave to amend. 

III. Complaint 

 In his one-count Complaint, Plaintiff sues Defendant Nurse J. Caffey. Plaintiff 

alleges a violation of the Eighth Amendment regarding his medical care and seeks six 

million dollars in damages. Plaintiff alleges that since January 2015, Defendant Caffey 

has been aware of Plaintiff’s severe chest and head cold, but has chosen not to provide 

him with any medication to treat the cold. Plaintiff states that he met with Defendant 

Caffey on January 28, February 17, and March 9, 2015, regarding his severe chest and 

head cold, and Defendant Caffey refused to provide Plaintiff with any medication for his 

cold, despite determining that he was ill. Plaintiff also states that he is AfricanAmerican, Defendant Caffey is a racist, and Defendant Caffey told him on January 28 

that “Black People always want something that they cannot have.” In addition, Plaintiff 

claims Defendant Caffey has denied his request for a blood test and, therefore, he will not 

be tested for hepatitis C or HIV/AIDS. 

IV. Failure to State a Claim

 Although pro se pleadings are liberally construed, Haines v. Kerner, 404 U.S. 519, 

520-21 (1972), conclusory and vague allegations will not support a cause of action. Ivey 

v. Bd. of Regents of the Univ. of Alaska, 673 F.2d 266, 268 (9th Cir. 1982). Further, a 

liberal interpretation of a civil rights complaint may not supply essential elements of the 

claim that were not initially pled. Id. 

 Not every claim by a prisoner relating to inadequate medical treatment states a 

violation of the Eighth or Fourteenth Amendment. To state a § 1983 medical claim, a 

plaintiff must show that the defendants acted with “deliberate indifference to serious 

medical needs.” Jett v. Penner, 439 F.3d 1091, 1096 (9th Cir. 2006) (quoting Estelle v. 

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Gamble, 429 U.S. 97, 104 (1976)). A plaintiff must show (1) a “serious medical need” 

by demonstrating that failure to treat the condition could result in further significant 

injury or the unnecessary and wanton infliction of pain and (2) the defendant’s response 

was deliberately indifferent. Jett, 439 F.3d at 1096 (quotations omitted). 

 “Deliberate indifference is a high legal standard.” Toguchi v. Chung, 391 F.3d 

1051, 1060 (9th Cir. 2004). To act with deliberate indifference, a prison official must 

both know of and disregard an excessive risk to inmate health; “the official must both be 

aware of facts from which the inference could be drawn that a substantial risk of serious 

harm exists, and he must also draw the inference.” Farmer v. Brennan, 511 U.S. 825, 

837 (1994). Deliberate indifference in the medical context may be shown by a 

purposeful act or failure to respond to a prisoner’s pain or possible medical need and 

harm caused by the indifference. Jett, 439 F.3d at 1096. Deliberate indifference may 

also be shown when a prison official intentionally denies, delays, or interferes with 

medical treatment or by the way prison doctors respond to the prisoner’s medical needs. 

Estelle, 429 U.S. at 104-05; Jett, 439 F.3d at 1096. 

 Deliberate indifference is a higher standard than negligence or lack of ordinary 

due care for the prisoner’s safety. Farmer, 511 U.S. at 835. “Neither negligence nor 

gross negligence will constitute deliberate indifference.” Clement v. California Dep’t of 

Corr., 220 F. Supp. 2d 1098, 1105 (N.D. Cal. 2002); see also Broughton v. Cutter Labs., 

622 F.2d 458, 460 (9th Cir. 1980) (mere claims of “indifference,” “negligence,” or 

“medical malpractice” do not support a claim under § 1983). “A difference of opinion 

does not amount to deliberate indifference to [a plaintiff’s] serious medical needs.” 

Sanchez v. Vild, 891 F.2d 240, 242 (9th Cir. 1989). A mere delay in medical care, 

without more, is insufficient to state a claim against prison officials for deliberate 

indifference. See Shapley v. Nevada Bd. of State Prison Comm’rs, 766 F.2d 404, 407 

(9th Cir. 1985). The indifference must be substantial. The action must rise to a level of 

“unnecessary and wanton infliction of pain.” Estelle, 429 U.S. at 105. 

. . . . 

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 Plaintiff alleges that Defendant Caffey failed to give him medication for a cold. In 

Health Needs Request forms attached to his Complaint, Plaintiff identified his symptoms 

as “sneezing, watery eyes, itchy throat & runny nose,” a “really [bad] cough,” and pain 

when he coughs and breathes. Plaintiff’s allegations regarding Defendant Caffey’s 

failure to treat his cold do not support a claim that Defendant Caffey was deliberately 

indifferent to a serious medical need or an excessive risk to inmate health. See Cooper v. 

Casey, 97 F.3d 914, 916-17 (7th Cir. 1996) (“A prison’s medical staff that refuses to 

dispense bromides for the sniffles or minor aches and pains or a tiny scratch or a mild 

headache or minor fatigue—the sorts of ailments for which many people who are not in 

prison do not seek medical attention—does not by its refusal violate the Constitution.”); 

Gibson v. McEvers, 631 F.2d 95, 98 (7th Cir. 1980) (“Plaintiff's allegation that he was 

refused medical treatment for a cold does not show deliberate indifference to a serious 

medical need, and therefore there was no violation of his constitutional rights.”). 

 In addition, although Plaintiff alleges that he requested and was denied a blood test 

for hepatitis or HIV/AIDS, he does not identify why he believes he needs such a test. He 

does not allege that he was a heightened risk of exposure to either disease, does not 

identify the basis for such a heightened risk, and does not allege that he communicated 

this information to Defendant Caffey prior to her rejection of his request. See Doe v. 

Wigginton, 21 F.3d 733, 738-39 (6th Cir. 1994) (no deliberate indifference when 

defendants adhered to policy requiring the testing of only inmates who request an HIV 

test and “provide[] a presumptive history of exposure”). Plaintiff’s vague and conclusory 

allegation that Defendant Caffey denied his request for a blood test is insufficient to state 

a claim. 

Finally, as to Defendant Caffey’s racial comment, “‘[v]erbal harassment or abuse 

. . . is not sufficient to state a constitutional deprivation under 42 U.S.C. § 1983.’” 

Oltarzewski v. Ruggiero, 830 F.2d 136, 139 (9th Cir. 1987) (quoting Collins v. Cundy, 

603 F.2d 825, 827 (10th Cir. 1979)); see also Kennan v. Hall, 83 F.3d 1083, 1092 (9th 

Cir. 1996); Hopson v. Frederickson, 961 F.2d 1378-79 (9th Cir. 1992) (racial slur and 

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threat did not constitute at § 1983 claim). If true, Defendant Caffey’s comment was 

plainly inappropriate and unprofessional, but does not rise to the level of a constitutional 

violation. 

Thus, the Court will dismiss without prejudice Count One and Defendant Caffey.

V. Leave to Amend 

 For the foregoing reasons, Plaintiff’s Complaint will be dismissed for failure to 

state a claim upon which relief may be granted. Within 30 days, Plaintiff may submit a 

first amended complaint to cure the deficiencies outlined above. The Clerk of Court will 

mail Plaintiff a court-approved form to use for filing a first amended complaint. If 

Plaintiff fails to use the court-approved form, the Court may strike the amended 

complaint and dismiss this action without further notice to Plaintiff. 

 Plaintiff must clearly designate on the face of the document that it is the “First 

Amended Complaint.” The first amended complaint must be retyped or rewritten in its 

entirety on the court-approved form and may not incorporate any part of the original 

Complaint by reference. Plaintiff may include only one claim per count. 

 A first amended complaint supersedes the original complaint. Ferdik v. Bonzelet, 

963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner & Co., 896 

F.2d 1542, 1546 (9th Cir. 1990). After amendment, the Court will treat an original 

complaint as nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised 

in the original complaint and that was voluntarily dismissed or was dismissed without 

prejudice is waived if it is not alleged in a first amended complaint. Lacey v. Maricopa 

County, 693 F.3d 896, 928 (9th Cir. 2012) (en banc). 

VI. Motion for Appointed Counsel

 In his Motion for Appointed Counsel, Plaintiff states that he is seriously mentally 

ill and needs counsel. There is no constitutional right to the appointment of counsel in a 

civil case. See Ivey v. Bd. of Regents of the Univ. of Alaska, 673 F.2d 266, 269 (9th Cir. 

1982). In proceedings in forma pauperis, the court may request an attorney to represent 

any person unable to afford one. 28 U.S.C. § 1915(e)(1). Appointment of counsel under 

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28 U.S.C. § 1915(e)(1) is required only when “exceptional circumstances” are present. 

Terrell v. Brewer, 935 F.2d 1015, 1017 (9th Cir. 1991). A determination with respect to 

exceptional circumstances requires an evaluation of the likelihood of success on the 

merits as well as the ability of Plaintiff to articulate his claims pro se in light of the 

complexity of the legal issue involved. Id. “Neither of these factors is dispositive and 

both must be viewed together before reaching a decision.” Id. (quoting Wilborn v. 

Escalderon, 789 F.2d 1328, 1331 (9th Cir. 1986)). 

 Having considered both elements, it does not appear at this time that exceptional 

circumstances are present that would require the appointment of counsel in this case. 

Thus, the Court will deny without prejudice Plaintiff’s Motion for Appointed Counsel. 

VII. Warnings

A. Release

 If Plaintiff is released while this case remains pending, and the filing fee has not 

been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court 

that he intends to pay the unpaid balance of his filing fee within 120 days of his release or 

(2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may 

result in dismissal of this action. 

B. Address Changes

 Plaintiff must file and serve a notice of a change of address in accordance with 

Rule 83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion 

for other relief with a notice of change of address. Failure to comply may result in 

dismissal of this action. 

 C. Copies

 Because Plaintiff is currently confined in an Arizona Department of Corrections 

unit subject to General Order 14-17, Plaintiff is not required to submit an additional copy 

of every filing for use by the Court, as would ordinarily be required by Local Rule of 

Civil Procedure 5.4. If Plaintiff is transferred to a unit other than one subject to General 

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Order 14-17, he will be notified of the requirements regarding copies for the Court that 

are required for inmates whose cases are not subject to General Order 14-17. 

 D. Possible “Strike”

 Because the Complaint has been dismissed for failure to state a claim, if Plaintiff 

fails to file an amended complaint correcting the deficiencies identified in this Order, the 

dismissal may count as a “strike” under the “3-strikes” provision of 28 U.S.C. § 1915(g). 

Under the 3-strikes provision, a prisoner may not bring a civil action or appeal a civil 

judgment in forma pauperis under 28 U.S.C. § 1915 “if the prisoner has, on 3 or more 

prior occasions, while incarcerated or detained in any facility, brought an action or appeal 

in a court of the United States that was dismissed on the grounds that it is frivolous, 

malicious, or fails to state a claim upon which relief may be granted, unless the prisoner 

is under imminent danger of serious physical injury.” 28 U.S.C. § 1915(g). 

E. Possible Dismissal

 If Plaintiff fails to timely comply with every provision of this Order, including 

these warnings, the Court may dismiss this action without further notice. See Ferdik, 963 

F.2d at 1260-61 (a district court may dismiss an action for failure to comply with any 

order of the Court). 

IT IS ORDERED: 

 (1) Plaintiff’s Motion for Appointed Counsel (Doc. 7) is denied without 

prejudice. 

 (2) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 2) is granted. 

 (3) As required by the accompanying Order to the appropriate government 

agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing 

fee of $1.80. 

(4) The Complaint (Doc. 1) is dismissed for failure to state a claim. Plaintiff 

has 30 days from the date this Order is filed to file a first amended complaint in 

compliance with this Order. 

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 (5) If Plaintiff fails to file an amended complaint within 30 days, the Clerk of 

Court must, without further notice, enter a judgment of dismissal of this action with 

prejudice that states that the dismissal may count as a “strike” under 28 U.S.C. § 1915(g). 

(6) The Clerk of Court must mail Plaintiff a court-approved form for filing a 

civil rights complaint by a prisoner. 

Dated this 15th day of May, 2015. 

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Revised 5/1/2013 1

Instructions for a Prisoner Filing a Civil Rights Complaint 

in the United States District Court for the District of Arizona

1. Who May Use This Form. The civil rights complaint form is designed to help incarcerated

persons prepare a complaint seeking relief for a violation of their federal civil rights. These

complaints typically concern, but are not limited to, conditions of confinement. This form should

not be used to challenge your conviction or sentence. If you want to challenge a state conviction

or sentence, you should file a petition under 28 U.S.C. § 2254 for a writ of habeas corpus by a

person in state custody. If you want to challenge a federal conviction or sentence, you should file

a motion under 28 U.S.C. § 2255 to vacate sentence in the federal court that entered the judgment.

2. The Form. Local Rule of Civil Procedure (LRCiv) 3.4(a) provides that complaints by

incarcerated persons must be filed on the court-approved form. The form must be typed or

neatly handwritten. The form must be completely filled in to the extent applicable. All questions

must be answered clearly and concisely in the appropriate space on the form. If needed, you may

attach additional pages, but no more than fifteen additional pages, of standard letter-sized paper.

You must identify which part of the complaint is being continued and number all pages. If you do

not fill out the form properly, you will be asked to submit additional or corrected information, which

may delay the processing of your action. You do not need to cite law. 

3. Your Signature. You must tell the truth and sign the form. If you make a false statement of a

material fact, you may be prosecuted for perjury.

4. The Filing and Administrative Fees. The total fees for this action are $400.00 ($350.00 filing fee

plus $50.00 administrative fee). If you are unable to immediately pay the fees, you may request

leave to proceed in forma pauperis. Please review the “Information for Prisoners Seeking Leave

to Proceed with a (Non-Habeas) Civil Action in Federal Court In Forma Pauperis Pursuant to 28

U.S.C. § 1915” for additional instructions.

5. Original and Judge’s Copy. You must send an original plus one copy of your complaint and of

any other documents submitted to the Court. You must send one additional copy to the Court if you

wish to have a file-stamped copy of the document returned to you. All copies must be identical to

the original. Copies may be legibly handwritten.

6. Where to File. You should file your complaint in the division where you were confined when

your rights were allegedly violated. See LRCiv 5.1(a) and 77.1(a). If you were confined in

Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. If you were confined

in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott Division. If you

were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file in the Tucson

Division. Mail the original and one copy of the complaint with the $400 filing and

administrative fees or the application to proceed in forma pauperis to:

Case 2:15-cv-00594-DGC--DMF Document 10 Filed 05/15/15 Page 10 of 19
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Phoenix & Prescott Divisions: OR Tucson Division:

U.S. District Court Clerk U.S. District Court Clerk

U.S. Courthouse, Suite 130 U.S. Courthouse, Suite 1500

401 West Washington Street, SPC 10 405 West Congress Street

Phoenix, Arizona 85003-2119 Tucson, Arizona 85701-5010

7. Change of Address. You must immediately notify the Court and the defendants in writing of any

change in your mailing address. Failure to notify the Court of any change in your mailing

address may result in the dismissal of your case.

8. Certificate of Service. You must furnish the defendants with a copy of any document you submit

to the Court (except the initial complaint and application to proceed in forma pauperis). Each

original document (except the initial complaint and application to proceed in forma pauperis) must

include a certificate of service on the last page of the document stating the date a copy of the

document was mailed to the defendants and the address to which it was mailed. See Fed. R. Civ.

P. 5(a), (d). Any document received by the Court that does not include a certificate of service may

be stricken. A certificate of service should be in the following form:

I hereby certify that a copy of the foregoing document was mailed

this (month, day, year) to:

Name: 

Address: 

 Attorney for Defendant(s)

 

(Signature)

9. Amended Complaint. If you need to change any of the information in the initial complaint, you

must file an amended complaint. The amended complaint must be written on the court-approved

civil rights complaint form. You may file one amended complaint without leave (permission) of

Court before any defendant has answered your original complaint. See Fed. R. Civ. P. 15(a). After

any defendant has filed an answer, you must file a motion for leave to amend and lodge (submit) a

proposed amended complaint. LRCiv 15.1. In addition, an amended complaint may not incorporate

by reference any part of your prior complaint. LRCiv 15.1(a)(2). Any allegations or defendants

not included in the amended complaint are considered dismissed. All amended complaints are

subject to screening under the Prison Litigation Reform Act; screening your amendment will take

additional processing time.

10. Exhibits. You should not submit exhibits with the complaint or amended complaint. Instead,

the relevant information should be paraphrased. You should keep the exhibits to use to support or

oppose a motion to dismiss, a motion for summary judgment, or at trial.

11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff of

any judge. The only appropriate way to communicate with the Court is by filing a written pleading

or motion.

Case 2:15-cv-00594-DGC--DMF Document 10 Filed 05/15/15 Page 11 of 19
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12. Completing the Civil Rights Complaint Form.

HEADING:

1. Your Name. Print your name, prison or inmate number, and institutional mailing address

on the lines provided.

2. Defendants. If there are four or fewer defendants, print the name of each. If you name

more than four defendants, print the name of the first defendant on the first line, write the

words “and others” on the second line, and attach an additional page listing the names of all

of the defendants. Insert the additional page after page 1 and number it “1-A” at the bottom.

3. Jury Demand. If you want a jury trial, you must write “JURY TRIAL DEMANDED” in

the space below “CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do so may

result in the loss of the right to a jury trial. A jury trial is not available if you are seeking

only injunctive relief.

Part A. JURISDICTION:

1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. § 1983

for state, county, or city defendants; “Bivens v. Six Unknown Federal Narcotics Agents” for

federal defendants; or “other.” If you mark “other,” identify the source of that authority. 

2. Location. Identify the institution and city where the alleged violation of your rights

occurred. 

3. Defendants. Print all of the requested information about each of the defendants in the

spaces provided. If you are naming more than four defendants, you must provide the

necessary information about each additional defendant on separate pages labeled “2-A,” “2-

B,” etc., at the bottom. Insert the additional page(s) immediately behind page 2.

Part B. PREVIOUS LAWSUITS:

You must identify any other lawsuit you have filed in either state or federal court while you

were a prisoner. Print all of the requested information about each lawsuit in the spaces provided.

If you have filed more than three lawsuits, you must provide the necessary information about each

additional lawsuit on a separate page. Label the page(s) as “2-A,” “2-B,” etc., at the bottom of the

page and insert the additional page(s) immediately behind page 2.

Part C. CAUSE OF ACTION:

You must identify what rights each defendant violated. The form provides space to allege

three separate counts (one violation per count). If you are alleging more than three counts, you

must provide the necessary information about each additional count on a separate page. Number

the additional pages “5-A,” “5-B,” etc., and insert them immediately behind page 5. Remember that

you are limited to a total of fifteen additional pages.

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1. Counts. You must identify which civil right was violated. You may allege the violation

of only one civil right per count.

2. Issue Involved. Check the box that most closely identifies the issue involved in your

claim. You may check only one box per count. If you check the box marked “Other,” you

must identify the specific issue involved.

3. Supporting Facts. After you have identified which civil right was violated, you must state

the supporting facts. Be as specific as possible. You must state what each individual

defendant did to violate your rights. If there is more than one defendant, you must identify

which defendant did what act. You also should state the date(s) on which the act(s)

occurred, if possible.

4. Injury. State precisely how you were injured by the alleged violation of your rights. 

5. Administrative Remedies. You must exhaust any available administrative remedies

before you file a civil rights complaint. See 42 U.S.C. § 1997e. Consequently, you should

disclose whether you have exhausted the inmate grievance procedures or administrative

appeals for each count in your complaint. If the grievance procedures were not available for

any of your counts, fully explain why on the lines provided.

Part D. REQUEST FOR RELIEF:

Print the relief you are seeking in the space provided. 

SIGNATURE:

You must sign your name and print the date you signed the complaint. Failure to sign the

complaint will delay the processing of your action. Unless you are an attorney, you may not bring

an action on behalf of anyone but yourself.

FINAL NOTE

You should follow these instructions carefully. Failure to do so may result in your complaint

being stricken or dismissed. All questions must be answered concisely in the proper space on the

form. If you need more space, you may attach no more than fifteen additional pages. But the form

must be completely filled in to the extent applicable. If you attach additional pages, be sure to

identify which section of the complaint is being continued and number the pages.

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Revised 5/1/2013 1 550/555

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

(Failure to notify the Court of your change of address may result in dismissal of this action.)

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

)

 , )

(Full Name of Plaintiff) Plaintiff, )

)

 vs. ) CASE NO. 

) (To be supplied by the Clerk)

(1) , )

(Full Name of Defendant) )

(2) , )

) CIVIL RIGHTS COMPLAINT

(3) ,) BY A PRISONER

)

(4) , ) G Original Complaint

Defendant(s). ) G First Amended Complaint

G Check if there are additional Defendants and attach page 1-A listing them. ) G Second Amended Complaint

A. JURISDICTION

1. This Court has jurisdiction over this action pursuant to:

G 28 U.S.C. § 1343(a); 42 U.S.C. § 1983

G 28 U.S.C. § 1331; Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971).

G Other: .

2. Institution/city where violation occurred: .

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B. DEFENDANTS

1. Name of first Defendant: . The first Defendant is employed as:

at .

(Position and Title) (Institution)

2. Name of second Defendant: . The second Defendant is employed as:

at .

(Position and Title) (Institution)

3. Name of third Defendant: . The third Defendant is employed as:

at .

(Position and Title) (Institution)

4. Name of fourth Defendant: . The fourth Defendant is employed as:

at .

(Position and Title) (Institution)

If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page.

C. PREVIOUS LAWSUITS

1. Have you filed any other lawsuits while you were a prisoner? G Yes G No

2. If yes, how many lawsuits have you filed? . Describe the previous lawsuits:

a. First prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

b. Second prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

c. Third prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

If you filed more than three lawsuits, answer the questions listed above for each additional lawsuit on a separate page.

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D. CAUSE OF ACTION

COUNT I

1. State the constitutional or other federal civil right that was violated: 

.

2. Count I. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count I. Describe exactly what each

Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal

authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies:

a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your

institution? G Yes G No

b. Did you submit a request for administrative relief on Count I? G Yes G No

c. Did you appeal your request for relief on Count I to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you

did not. 

.

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COUNT II

1. State the constitutional or other federal civil right that was violated: 

.

2. Count II. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count II. Describe exactly what each

Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal

authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies.

a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your

institution? G Yes G No

b. Did you submit a request for administrative relief on Count II? G Yes G No

c. Did you appeal your request for relief on Count II to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you

did not. 

.

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COUNT III

1. State the constitutional or other federal civil right that was violated: 

.

2. Count III. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count III. Describe exactly what each

Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal

authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies.

a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your

institution? G Yes G No

b. Did you submit a request for administrative relief on Count III? G Yes G No

c. Did you appeal your request for relief on Count III to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you

did not. 

.

If you assert more than three Counts, answer the questions listed above for each additional Count on a separate page.

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E. REQUEST FOR RELIEF

State the relief you are seeking:

.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on 

DATE SIGNATURE OF PLAINTIFF

(Name and title of paralegal, legal assistant, or

other person who helped prepare this complaint)

(Signature of attorney, if any)

(Attorney’s address & telephone number)

ADDITIONAL PAGES

All questions must be answered concisely in the proper space on the form. If you need more space, you may attach

no more than fifteen additional pages. But the form must be completely filled in to the extent applicable. If you

attach additional pages, be sure to identify which section of the complaint is being continued and number all pages.

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