Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-3_19-cv-08306/USCOURTS-azd-3_19-cv-08306-0/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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WO SC

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Glen Wilson,

Plaintiff, 

v. 

Yuri M. Lewicky, et al.,

Defendants.

No. CV 19-08306-PCT-JAT (DMF)

ORDER

Plaintiff Glen Wilson, who is confined in the Federal Correctional Institution in 

Phoenix, Arizona, filed a pro se civil rights Complaint (Doc. 1) pursuant to 28 U.S.C. 

§ 1331 and Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics, 403 

U.S. 388 (1971), and an Application to Proceed In Forma Pauperis (Doc. 4). The Court 

granted the Application and dismissed the Complaint (Doc. 6).

1 Plaintiff has filed 

“Plaintiff’s Amended Complaint” (hereafter, “First Amended Complaint”) (Doc. 9). In the 

First Amended Complaint, Plaintiff cites 28 U.S.C. § 1331 and medical malpractice as the 

bases for subject matter jurisdiction. As discussed below, Plaintiff fails to allege facts to 

support that this Court has federal question subject matter jurisdiction under 28 U.S.C. 

§ 1331. Accordingly, the Court will dismiss the First Amended Complaint with leave to 

amend using the court-approved form complaint for use by prisoners. 

1

 In the Order, the Court indicated that it was dismissing the Complaint with leave 

to amend, but the final page of the Order dismissed the Complaint and this action and 

Judgment was entered by the Clerk of Court (Doc. 8). The Court will vacate entry of 

Judgment and order this case reopened.

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I. 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)). 

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

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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 First Amended Complaint will be dismissed for lack of subject matter 

jurisdiction with leave to amend because it may possibly be amended to support subject 

matter jurisdiction.2

II. First Amended Complaint

In his one-count First Amended Complaint, Plaintiff asserts a claim for medical 

malpractice. Plaintiff sues Dr. Yuri Lewicky, an orthopedic surgeon, and Northern Arizona 

Orthopaedics Hospital, Ltd. (“Hospital”), a hospital with which Dr. Lewicky is or was

affiliated.3 Plaintiff does not allege the relief sought in his First Amended Complaint, but 

he sought compensatory and punitive relief in his Complaint. 

A. Background

Plaintiff was convicted of federal offenses on April 26, 2006 and sentenced to prison 

for five years followed by supervised release for five years. United States v. Wilson, 

No.3:05cr00657-PCT-JAT (D. Ariz. Apr. 26, 2006), Doc. 43. Plaintiff was released on 

supervised release after completing his prison term, but his supervised release has been 

revoked multiple times for violations of the terms of that release. Id., Docs. 87, 103, 107 

(amended order), 124, and 140. At the time of the events at issue in the First Amended 

Complaint, Plaintiff was on supervised release. Subsequent to the events at issue in the 

First Amended Complaint, Plaintiff was again charged with violating the conditions of his 

supervised release and on August 24, 2018, the Court revoked supervised release and 

sentenced Plaintiff to serve 36 months in prison. Id., Doc. 140. While in prison, Plaintiff

filed this action.

2

 Plaintiff states that his Complaint was dismissed because he sought relief pursuant 

to 42 U.S.C. § 1983, rather than 28 U.S.C. § 1331. Plaintiff mischaracterizes the reasons 

for dismissal. Claims under either Bivens, § 1983, or the Federal Tort Claims Act, are all 

predicated on federal question subject matter jurisdiction under 28 U.S.C. § 1331. 

However, Plaintiff did not seek relief for acts taken by persons acting under color of state 

law and did not, therefore state a claim under § 1983. 

3

 See https://www.northazortho.com/ (last accessed Apr. 7, 2020).

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B. Plaintiff’s Allegations

Except as otherwise indicated, Plaintiff alleges the following:

On June 7, 2016, while on supervised release, Plaintiff injured his left knee and was 

seen in the emergency room of Indian Health Service4in Fort Defiance, Arizona.5 Dr. 

Oseni ordered an MRI of Plaintiff’s left knee, which was performed on June 16, 2016. 

Plaintiff returned home with instructions to use crutches, to stay off his feet as much as 

possible, and to elevate and ice his left knee. Plaintiff received a “referral from Dr. 

Marshall L. Cook, to report to Northern Arizona Orthopedic Hospital” (“the Hospital”). 

(Doc. 9 at 2.) Plaintiff reported to the Hospital on August 22, 2016 for examination. Dr. 

Bourck Cashmore referred Plaintiff to Defendant Dr. Lewicky. On August 25, 2016, 

Plaintiff visited Dr. Lewicky, who recommended arthroscopic assisted ACL (anterior 

cruciate ligament) and PCL (posterior cruciate ligament) reconstruction in addition to open 

MCL (medial collateral ligament) and posterior oblique ligament reconstruction and 

removal of tibial hardware, which would require an overnight stay. The surgery was 

ordered and, apparently, performed. Plaintiff does not allege whether Dr. Lewicky is or 

was a federal employee or in any way affiliated with Indian Health Service. Similarly, 

Plaintiff does not allege that the Hospital is or was an Indian Health Service, or other 

federal, facility. Plaintiff does not identify any injury he suffered as the result of 

Defendants’ conduct in his First Amended Complaint, but in his Complaint, Plaintiff 

alleged that his surgical wound never completely closed or healed and that he was in 

constant pain. 

III. Subject Matter Jurisdiction

Federal courts are courts of limited jurisdiction and only have subject matter 

jurisdiction over matters authorized by the Constitution and Congress. A federal district 

4

 The Indian Health Service is a division of the Public Health Service of the United 

States Department of Health and Human Services. Benavidez v. United States, 177 F.3d 

927, 928 n.1 (10th Cir. 1999). 

5

 Plaintiff is Native American. See https://www.bop.gov/inmateloc/, search 

Register# 83048-008 (last accessed Apr. 8, 2020). 

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court, like this one, may only exercise subject matter jurisdiction based on federal question 

subject matter jurisdiction under 28 U.S.C. § 1331 or diversity subject jurisdiction under 

28 U.S.C. § 1332. 

Section 1331 provides that “The district courts shall have original jurisdiction of all civil 

actions arising under the Constitution, laws, or treaties of the United States.” Plaintiff 

asserts a claim for medical malpractice, but he fails to identify how a medical malpractice 

claim arises under the Constitution, laws, or treaties of the United States. Plaintiff does 

not allege that Dr. Lewicky was a federal employee or even affiliated with Indian Health 

Care Services, nor has Plaintiff alleged that the Hospital was a federal facility. 

Assuming either Dr. Lewicky or the Hospital were affiliated with Indian Health 

Service, or another federal entity, Plaintiff’s medical malpractice claim may arise under 

the Federal Tort Claims Act (FTCA) for purposes of federal question subject matter 

jurisdiction. See Benavidez v. United States, 177 F.3d 927, 930 (10th Cir. 1999) (FTCA 

applied to claim that government psychologist was negligent); Simmons v. United States, 

805 F.2d 1363 (9th Cir. 1996) (holding that health service counselor was acting within 

scope of his employment in providing mental health counseling to patient when he 

wrongfully engaged her in a sexual relationship, and thus government was liable to patient 

under FTCA on theory of respondeat superior). But see Tsosie v. United States, 452 F.3d 

1161, 1165 (10th Cir. 2006) (physician at Indian Health Service facility working under 

non-personal services contract at emergency room was an independent contractor and 

could not be sued under the FTCA); Woodruff v. Covington, 389 F.3d 1117, 1128-29 (10th 

Cir. 2004) (FTCA did not extend to independent contractor physicians); Carrillo v. United 

States, 5 F.3d 1302, 1305 (9th Cir. 1993) (same); Bernie v. United States, 712 F.2d 1271, 

1273-74 (8th Cir. 1983) (where IHS did not supervise day-to-day operations of physicians 

employed by independent contractor, FTCA did not afford basis for relief); Yoe v. United 

States, No. CV18-08112-PCT-SPL, 2019 WL 3501457, at *3 (D. Az. Aug. 1, 2019 

(physicians practicing medicine under contract in federal facilities qualify as independent 

contractors under the FTCA, not government employees.).

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The FTCA authorizes “claims against the United States, for money damages . . . for 

injury or loss of property . . . caused by the negligent or wrongful act or omission of any 

employee of the Government while acting within the scope of his office or employment.” 

28 U.S.C. § 1346(b). Specifically, the FTCA waives the United States’ sovereign 

immunity from suit for injury or loss of property, or personal injury or death caused by the 

negligent or wrongful act or omission of any employee of the Government while acting 

within the scope of his or her office or employment, under the circumstances where the 

United States, if a private person, would be liable to the claimant in accordance with the 

law of the place where the act or omission occurred. 28 U.S.C. § 1346(b)(1). Thus, relief 

under the FTCA may be sought for negligent acts or omissions of employees or agents of 

the federal government. See Vander v. U.S. Dep’t of Justice, 268 F.3d 661, 663 (9th Cir. 

2001); Westbay Steel, Inc. v. United States, 970 F.2d 648, 651 (9th Cir. 1992). Claims 

under the FTCA may only be brought against the United States. 28 U.S.C. §§ 1346(b), 

2679(a); Allen v. Veterans Admin., 749 F.2d 1386, 1388 (9th Cir. 1984) (individual 

agencies of the United States may not be sued). 

Under the statutory procedure set forth in 28 U.S.C. § 2675(a), a “tort claimant may 

not commence proceedings in court against the United States without first filing his claim 

with an appropriate federal agency and either receiving a conclusive denial of the claim 

from the agency or waiting for six months to elapse without a final disposition of the claim 

being made.” Jerves v. United States, 966 F.2d 517, 519 (9th Cir. 1992) (emphasis added); 

see Brady v. United States, 211 F.3d 499, 502 (9th Cir. 2000) (a claimant under the FTCA 

must comply with § 2675(a) before a district court can exercise subject matter jurisdiction 

over the claim); Caton v. United States, 495 F.2d 635, 638 (9th Cir. 1974). The Ninth 

Circuit Court of Appeals has “repeatedly held that this ‘claim requirement of section 2675 

is jurisdictional in nature and may not be waived.’” Jerves, 966 F.2d at 519 (quoting Burns 

v. United States, 764 F.2d 722, 724 (9th Cir. 1985)). 

Plaintiff has not identified a basis for bringing his medical malpractice claim in 

federal court because he has not alleged facts to support that either Defendant was a federal 

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employee or facility, or that either acted negligently. For that reason, the Court will dismiss 

the First Amended Complaint for lack of subject matter jurisdiction. If Plaintiff elects to

seek relief under the FTCA, Plaintiff must name the United States as the defendant and 

allege facts to support that Dr. Lewicky or the Hospital were either a federal employee or 

facility and facts to support how each acted negligently. In addition, Plaintiff must allege 

when and how he submitted a claim to the appropriate federal entity and either identify 

when his claim was conclusively denied or allege that six months have elapsed without a 

final disposition of his FTCA claim. 

IV. Leave to Amend

For the foregoing reasons, Plaintiff’s First Amended Complaint will be dismissed 

for lack of subject matter jurisdiction. Within 30 days, Plaintiff may submit a second 

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

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

fails to use the court-approved form, the Court may strike the second 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 “Second 

Amended Complaint.” The second 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 or First Amended Complaint by reference. Plaintiff may include 

only one claim per count. 

A second amended complaint supersedes the original Complaint and First Amended 

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 the original Complaint and First Amended Complaint as nonexistent. Ferdik, 

963 F.2d at 1262. Any cause of action that was raised in the original Complaint or First 

Amended Complaint and that was voluntarily dismissed or was dismissed without 

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

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

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V. 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. 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) The Clerk of Court must vacate the entry of Judgment (Doc. 8) on January 

21, 2020 and reopen this case.

(2) The First Amended Complaint (Doc. 9) is dismissed for lack of subject 

matter jurisdiction. Plaintiff has 30 days from the date this Order is filed to file a second 

amended complaint in compliance with this Order.

(3) If Plaintiff fails to file a second amended complaint within 30 days, the Clerk 

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

prejudice for lack of subject matter jurisdiction and deny any pending unrelated motions 

as moot.

. . . .

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

civil rights complaint by a prisoner. 

Dated this 20th day of April, 2020.

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Revised 3/11/16 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. This section does not apply to 

inmates housed at an Arizona Department of Corrections facility that participates in 

electronic filing.

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:

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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. This section does not apply to inmates housed at an Arizona Department of 

Corrections facility that participates in electronic filing.

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 within 21 days after serving it or within 21 days after any defendant has filed 

an answer, whichever is earlier. See Fed. R. Civ. P. 15(a). Thereafter, 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.

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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 3/11/16 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,

v. 

(1) _______________________________________ , (Full Name of Defendant)

(2) _______________________________________ ,

(3) _______________________________________ ,

(4) _______________________________________ ,

Defendant(s).

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

CASE NO. __________________________________ 

(To be supplied by the Clerk)

CIVIL RIGHTS COMPLAINT

BY A PRISONER

G Original Complaint

G First Amended Complaint

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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2

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:

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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4

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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5

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.

Case 3:19-cv-08306-JAT--DMF Document 11 Filed 04/20/20 Page 19 of 19