Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_06-cv-00098/USCOURTS-azd-2_06-cv-00098-0/pdf.json

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

---

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

JDDL-K

JDN

WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Stanley Jay Hoke, 

Plaintiff, 

vs.

Joseph Arpaio,

Defendant. 

)

)

)

)

)

)

)

)

)

)

)

No. CV 06-0098-PHX-DGC (LOA)

ORDER

This is a civil rights action pursuant to 42 U.S.C. § 1983 filed by an inmate confined

in the Durango Jail in Phoenix, Arizona. The Court will dismiss the action with leave to

amend.

A. Application to Proceed In Forma Pauperis & Filing Fee.

Plaintiff’s request to proceed in forma pauperis will be grant ed. Pursuant to 28

U.S.C. § 1915(b)(1), Plaintiff is required to pay the statutory filing fee of $250.00 for this

act ion. No initial partial filing fee will be assessed by this Order. 28 U.S.C. § 1915(b)(1).

By separate order, the Court will direct the appropriat e agency to collect monthly payments

of 20 percent of the preceding month’s income credited to Plaintiff’s trust account . These

payments will be forwarded by the ap p ropriate agency to the Clerk of Court each time the

amount in Plaintiff’s account exceeds $10.00, until the filing fee is paid in full. 28 U.S.C. §

1915(b)(2).

Plaint iff should take notice that if he is released before the filing fee is paid in full,

he must pay the remaining unpaid amount of t he filing fee within 120 days of the date of

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 1 of 19
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

JDDL-K - 2 -

his release. If Plaintiff fails to pay the remainder of the filing fee within 120 days of t he date

of his release, the action will be dismissed, unless Plaintiff shows good cause, in writing,

why he is unable to pay the remainder of the filing fee.

B. Statutory Screening of Prisoner Complaints.

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

against a governmental entity or officer or employee of a governmental entity. 28 U.S.C.

§ 1915A(a). The Court must dismiss a complaint or portion t hereof if Plaintiff has raised

claims that are legally “frivolous or malicious,” that fail to state a claim up on 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). 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 the

complaint before dismissal of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th

Cir. 2000) (en banc). The Court is required to grant leave to amend “if a complaint can

possibly be saved,” but not if the Complaint “ lacks merit entirely.” Id. at 1129. A court

therefore should grant leave to amend if the pleading could be cured by the allegation of

other facts, or if it appears at all possible that the defect can be corrected. Id. at 1130. The

Court should not , however, advise the litigant how to cure the defects. This type of advice

“would undermine the dist rict judges’ role as impartial decisionmakers.” Pliler v. Ford, 542

U.S. 225, 231 (2004); see also Lopez, 203 F.3d at 1131 n.13 (declining to decide whether

court was required to inform litigant of deficiencies). Plaint iff’s Comp laint will be dismissed

for failure to state a claim, with leave to amend because t he complaint may possibly be

saved by amendment.

C. Complaint.

Plaintiff's Complaint concerns the condit ions at the Durango Jail in Phoenix,

Arizona. In Count I, Plaintiff alleges that the jail is housing twice as many inmates as it was

designed to hold. In Count II, Plaint iff asserts that no food handlers cards are required at

the jail. And in Count III, Plaintiff states that the building is condemned and that he

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 2 of 19
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

JDDL-K - 3 -

inhaled asbestos. Plaintiff claims that he has been sick as a result of these violations. For

relief, Plaintiff requests monetary damages.

D. Failure to State a Claim.

To st at e a § 1983 claim, a plaintiff must allege that he suffered specific injury as a

result of the specific conduct of a defendant, and show an affirmative link between the

injury and that conduct. Rizzo v. Goode, 423 U.S. 362, 371-72, 377 (1976). Plaintiff has not

alleged any specific conduct of a defendant and has not connected any of his claims t o

Defendant Arpaio. 

Arpaio cannot be liable simply based upon his position. There is no respondeat

superior liability under § 1983, so a defendant ’s position as the supervisor of a person who

allegedly violated Plaintiff’s constitutional rights does not impose liability. Monell v. Dep’t

of Soc. Servs., 436 U.S. 658 (1978); Taylor v. List, 880 F.2d 1040, 1045 (9th Cir. 1989). “A

supervisor is only liable for constitutional violations of his subordinates if the supervisor

participated in or directed the violations, or knew of t he violations and failed to act to

prevent t hem.” Taylor, 880 F.2d at 1045. There are no allegations to show that Arpaio

particip ated in or directed the alleged constitutional violations, or that he knew of the

violations and failed to act to prevent them. 

If the evidence justifies it, Plaintiff may name persons in their individual capacities.

If he does so, he must write short, plain statements telling the court: (1) the constitutional

right Plaintiff believes was violated; (2) the name of the person who violated the right ; (3)

exact ly what that individual did or failed to do; (4) how the action or inaction of that person

is connected to the violat ion of Plaintiff’s constitutional right; and (5) what specific injury

Plaintiff suffered because of that person’s conduct. Rizzo, 423 U.S. at 371-72, 377. Plaintiff

must repeat t his p rocess for each person he names as a Defendant. If Plaintiff fails to do

this for any person named as a Defendant, the court will dismiss that Defendant from this

action.

Regarding Arpaio in his official cap acit y, a suit against him officially is equivalent

to a suit brought against the governmental entity. See Will v. Michigan Dep’t of State

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 3 of 19
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

JDDL-K - 4 -

Police,491 U.S. 58, 71 (1989). In this case, the governmental entity is Maricopa County.

A county is the liable entity under § 1983 when its policy, practice or custom causes

constitutional injury. See Monell, 436 U.S. at 694. In that instance, the county’s liability

is based on the actions of its policymakers, such as a sheriff. See Cortez v. Count y of Los

Angeles, 294 F.3d 1186, 1188-92 (9th Cir. 2001) (finding that sheriff acted on behalf of

county, subjecting county to § 1983 liability ). A sheriff could be sued in his official

capacity for a policy, practice, or custom he put into place on behalf of the county that

caused t he constitutional injury. There are no allegations to support liability against

Arp aio in his official capacity. At this juncture, Plaintiff's allegations are insufficient to

state a claim under § 1983. 

E. Hart v. Hill

In his Complaint, Plaintiff refers to Hart v. Hill, No. CIV 77-0479-PHX-EHC (MS) (D.

Ariz.), claiming that the conditions of his confinement violate an Amended Judgment in

that action. Jurisdiction to enforce t he judgment is retained by the court which entered it.

Jeff D. v. Kempthorne, 365 F.3d 844, 853 (9th Cir. 2004). A civil rights action is not the

proper means by which to enforce the decree. Cagle v. Sutherland, 334 F.3d 980, 986 (11th

Cir. 2003); Klein v. Zavaras, 80 F.3d 432, 435 (10th Cir. 1996); DeGidio v. Pung, 920 F.2d 525,

534 (8th Cir. 1990); Green v. McKaskle, 788 F.2d 1116, 1122-23 (5t h Cir. 1986). Standing

alone, remedial orders cannot serve as a substantive basis for a § 1983 claim for damages

because such orders do not create “rights, privileges, or immunities secured by the

Constitution and laws.” Green, 788 F.3d at 1123-24. Remedial decrees are the means by

which unconstitutional conditions are correct ed but they do not create or enlarge

constitutional rights. Id. at 1123. To the extent Plaintiff seeks to enforce Hart v. Hill, his

claim is not properly brought in this action. Instead, his allegations must separately st at e

a violation of a constitutional right. 

F. 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. Plaint iff may amend his Complaint to cure the

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 4 of 19
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

JDDL-K - 5 -

deficiencies outlined above. The Clerk of Court will be directed to provide Plaintiff with a

Court-approved form for filing a civil rights complaint. Plaintiff is advised that the amended

complaint must be retyped or rewritten in its entirety on t he court-approved form and may

not incorp orate any part of the original Complaint by reference. Any amended complaint

submitted by Plaintiff should be clearly designated as such on the face of the document.

Plaintiff is also reminded that in an Amended Complaint, he may only include one

claim per count. The “one claim per count” rule is set forth in the form Complaint and

accompanying instructions, and is a requirement imposed by the local rules of this Court.

See LRCiv 3.4(a) (complaint must be in accordance with the instructions provided with the

form). 

An 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 original pleading is treated as nonexistent.

Ferdik, 963 F.2d at 1262. Thus, causes of action alleged in an original complaint which are

not alleged in an amended complaint are waived. King v. Atiyeh, 814 F.2d 565, 567 (9th Cir.

1987).

G. Address Changes.

In t he notice of assignment issued in this action (Doc. #2), Plaintiff was advised he

must file a notice of change of address if his address changes. Plaint iff is again reminded

t hat at all times during the pendency of this action, Plaintiff shall immediately advise the

Court of any change of address and its effective date. Such notice shall be captioned

“ NOTICE OF CHANGE OF ADDRESS.” Plaintiff shall serve a copy of the Notice of

Change of Address on all opposing p art ies. The notice shall contain only information

pertaining to the change of address and its effective date, and shall not include a motion

for other relief. Failure to timely file a notice of change of address may result in the

dismissal of the action for failure to prosecute p ursuant to Rule 41(b) of the Federal Rules

of Civil Procedure.

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 5 of 19
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

JDDL-K - 6 -

H. Warning of Possible Dismissal.

Plaintiff should take note that if he fails to timely comply with every provision of this

Order, this action will be dismissed without further not ice. See Ferdik, 963 F.2d at 1260-

61(district court may dismiss action for failure to comply with any order of the Court ).

Moreover, 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 of this action will count as a “strike” under t he “ t hree st rikes” provision of the

Prison Litigation Reform Act. See 28 U.S.C. § 1915(g).

IT IS THEREFORE ORDERED that: 

(1) Plaintiff’s Application to Proceed In Forma Pauperis is granted pursuant to 28

U.S.C. § 1915(a)(1).

(2) Plaintiff is obligat ed t o pay the statutory filing fee of $250.00 for this action.

Plaintiff is assessed no initial partial filing fee. All fees shall be collected and paid in

accordance with this Court’s Order to t he ap p ropriate government agency filed

concurrently herewith.

(3) The Complaint is dismissed for failure to state a claim. Plaintiff shall have 30

days from the date this Order is filed to file an Amended Complaint in compliance with this

Order.

(4) The Clerk of Court shall enter a judgment of dismissal of this action with

prejudice and without further not ice to Plaintiff, if Plaintiff fails to file an amended

complaint within thirty (30) day s of the date this Order is filed. Upon entry of judgment,

the Clerk shall make an entry on the docket in this mat t er indicating that the dismissal of

this action falls within the purview of 28 U.S.C. § 1915(g).

(5) Aside from the two copies of the petition or amended petition that must be

submitted pursuant to Rule 3.5(a), of the Local Rules of Civil Procedure, a clear, legible

copy of every pleading or other document filed shall accompany each original pleading or

other document filed with the Clerk for use by the District Judge or Magistrate Judge to

whom the case is assigned. See LRCiv 5.4. Failure t o comply with this requirement may

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 6 of 19
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

JDDL-K - 7 -

result in the pleading or document being stricken without further notice to Plaintiff.

(6) The Clerk of Court shall provide to Plaint iff a current court-approved form for

filing a civil rights complaint by a prisoner.

DATED this 26th day of January, 2006.

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 7 of 19
Revised 2/7/05 1

INFORMATION AND INSTRUCTIONS FOR A

PRISONER FILING CIVIL RIGHTS COMPLAINT

 IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

I. General Information About the Civil Rights Complaint Form:

A. The Form. The civil rights complaint form is designed to help prisoners prepare a

complaint seeking relief for a violation of their federal civil rights. Local Rule of Civil Procedure

3.4(a) requires that prisoner civil rights complaints be filed on the court-approved form. Your

complaint must be typewritten or legibly handwritten. All information must be clearly and

concisely written, only in the space provided on the form. If needed, you may attach no more

than fifteen additional pages of standard letter size paper to continue any part of the complaint.

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

B. Your Signature. You must sign the complaint. Your signature constitutes a certificate that:

1) you have read the complaint; 2) to the best of your knowledge, information and belief formed

after reasonable inquiry it is well grounded in fact and law; and 3) it is not being filed for any

improper purpose. Please review Rule 11 of the Federal Rules of Civil Procedure. Rule 11

provides for the imposition of sanctions if the complaint is signed in violation of the Rule. 

C. The Filing Fee. You must pay the $250.00 filing fee. If you are unable to pay the filing

fee when the complaint is filed, 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 more

information.

D. Court Divisions. If you resided in Maricopa, Pinal, Yuma, La Paz, or Gila county when

your rights were allegedly violated, you should file your complaint in the Phoenix Division of

the court. If you resided in Apache, Navajo, Coconino, Mohave, or Yavapai county when your

rights were allegedly violated, you should file your complaint in the Prescott Division of the

court. If you resided in Pima, Cochise, Santa Cruz, Graham, or Greenlee county when your

rights were allegedly violated, you should file your complaint in the Tucson Division of the court.

See LRCiv 5.1(a) and 77.1(a). 

You should mail THE ORIGINAL AND ONE COPY of your complaint with the

$250.00 filing fee or the application to proceed in forma pauperis to:

Phoenix & Prescott Divisions: OR Tucson Division:

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

U.S. Courthouse, Suite 321 U.S. Courthouse, Suite 1500

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 8 of 19
2

401 West Washington Street, SPC 10 405 West Congress Street

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

E. Certificate of Service on Defendants. You must furnish the opposing party or their attorney

with a copy of any document you submit to the court (except the initial complaint and

application to proceed in forma pauperis). Pursuant to Rules 5(a) and (d) of the Federal Rules

of Civil Procedure, each original document (except the initial complaint and application for leave

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 opposing party or their

attorney and the address to which it was mailed. Any document received by the court which

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 day of (month) , (year) , to:

Name: 

Address: 

 Attorney for Defendant(s)/Respondent(s)

 

(Signature)

F. Original and Judge's Copy. You must furnish an original and one copy of any document

submitted to the court. You must furnish one additional copy to the clerk if you wish to have

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

original.

G. Exhibits. You should not submit exhibits with the complaint. Instead, the relevant

information should be paraphrased in the complaint. You should keep the exhibits to use to

support or oppose a motion for summary judgment or at trial.

H. Change of Address. You must immediately notify the clerk and the opposing party or their

attorney 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.

I. 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 courtapproved civil rights complaint form. Rule 15(a) of the Federal Rules of Civil Procedure allows

you to file one amended complaint prior to any defendant filing an answer. After any defendant

has filed an answer, you must file a motion for leave to amend and lodge a proposed amended

complaint. Local Rule of Civil Procedure 15.1(a)(2) prohibits any amended pleading from

referencing any prior pleading. Further, any allegations or defendants not included in the

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 9 of 19
3

amended complaint are considered dismissed.

J. Letters and Motions. It is generally inappropriate to write a letter to any of the District

Judges, Magistrates Judges, or the staff of any of the judicial officers. The appropriate way to

communicate with these persons is by filing a written pleading or motion. 

II. Completing the Civil Rights Complaint Form:

HEADING:

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

the lines provided. 

2. Defendants. Print the names of each of your defendants. If you name more than

four defendants, you should print the name of one defendant and "see additional page

for defendants" in the space provided. On the additional page you must list the names

of all of the defendants. This additional page should be inserted after page 1 and

numbered as page "1-A" at the bottom of the page. The initial complaint must contain

the names of all of the parties (plaintiffs as well as defendants) in the heading (or on the

additional page if more than four defendants). See Rule 10(a) of the Federal Rules of

Civil Procedure.

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

on the line below "CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do so

will 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. Plaintiff. Print all of the requested information on the spaces provided. 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 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 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

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 10 of 19
4

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 the defendant(s) 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.

 

1. Counts. You must identify which civil right was violated. YOU MAY ALLEGE THE

VIOLATION OF ONLY ONE CIVIL RIGHTS CLAIM 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 in the space provided.

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

to 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

need to identify which defendant did what act. You also need to 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. Exhaustion of administrative remedies is a prerequisite

to filing a civil rights complaint. 42 U.S.C. § 1997e requires prisoners to exhaust the

available administrative remedies before being allowed to file a civil rights action.

Consequently, you must disclose whether you have exhausted the inmate grievance

procedures or administrative appeals for each count in your complaint. If one of your

counts is exempt from the grievance procedures or administrative appeals, fully explain

the exemption 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. Your signature

must be an original signature, not a photocopy. 

FINAL NOTE

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

complaint being stricken or dismissed by the court. All questions must be answered concisely

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 11 of 19
5

in the proper space on the form. If needed, you may attach no more than fifteen additional

pages. The form, however, 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.

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 12 of 19
Revised 2/7/05 1 550/555

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

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)

 , )

)

 , )

) CIVIL RIGHTS COMPLAINT

 ,) BY A PRISONER

)

 , ) G Original Complaint

(Full Name of Each Defendant) Defendant(s). ) G First Amended Complaint

) G Second Amended Complaint

A. JURISDICTION

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

a. G 28 U.S.C. § 1343(a)(3); 42 U.S.C. § 1983

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

c. G Other: (Please specify.) .

2. Name of Plaintiff: .

Present mailing address: .

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

Institution/city where violation occurred: .

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 13 of 19
2

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

at . (Position and Title) (Institution)

The first Defendant is sued in his/her: G individual capacity G official capacity (check one or both).

Explain how the first Defendant was acting under color of law: 

.

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

at . (Position and Title) (Institution)

The second Defendant is sued in his/her: G individual capacity G official capacity (check one or both).

Explain how the second Defendant was acting under color of law: 

.

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

at . (Position and Title) (Institution)

The third Defendant is sued in his/her: G individual capacity G official capacity (check one or both).

Explain how the third Defendant was acting under color of law: 

.

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

at . (Position and Title) (Institution)

The fourth Defendant is sued in his/her: G individual capacity G official capacity (check one or both).

Explain how the fourth Defendant was acting under color of law: 

.

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

B. PREVIOUS LAWSUITS

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

2. If your answer is "yes," how many lawsuits have you filed? . Describe the previous lawsuits in the

spaces provided below.

3. First prior lawsuit:

a. Parties to previous lawsuit:

Plaintiff: .

Defendants: 

.

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 14 of 19
3

b. Court: (If federal court, identify the district; if state court, identify the county.) 

.

c. Case or docket number: .

d. Claims raised: 

e. Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?) 

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

4. Second prior lawsuit:

a. Parties to previous lawsuit:

Plaintiff: .

Defendants: 

.

b. Court: (If federal court, identify the district; if state court, identify the county.) 

.

c. Case or docket number: .

d. Claims raised: 

.

e. Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?) 

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

5. Third prior lawsuit:

a. Parties to previous lawsuit:

Plaintiff: .

Defendants: 

.

b. Court: (If federal court, identify the district; if state court, identify the county.) 

.

c. Case or docket number: .

d. Claims raised: 

.

e. Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?) 

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

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

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 15 of 19
4

C. CAUSE OF ACTION

COUNT I

1. The following constitutional or other federal civil right has been violated by the Defendant(s): 

.

2. Count I involves: (Check only one; if your claim involves more than one issue, each issue should be stated

in a different count) 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 to violate your rights. State the facts clearly in your own words without citing legal

authority or arguments).

.

4. Injury: (State how you have been 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 to the highest level, briefly explain

why you did not. 

.

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 16 of 19
5

COUNT II

1. The following constitutional or other federal civil right has been violated by the Defendant(s): 

.

2. Count II involves: (Check only one; if your claim involves more than one issue, each issue should be stated

in a different count) 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 to violate your rights. State the facts clearly in your own words without citing

legal authority or arguments).

.

4. Injury: (State how you have been 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 to the highest level, briefly explain

why you did not. 

.

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 17 of 19
6

COUNT III

1. The following constitutional or other federal civil right has been violated by the Defendant(s): 

.

2. Count III involves: (Check only one; if your claim involves more than one issue, each issue should be stated

in a different count) 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 to violate your rights. State the facts clearly in your own words without citing

legal authority or arguments).

.

4. Injury: (State how you have been 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 to the highest 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.)

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 18 of 19
7

D. REQUEST FOR RELIEF

State briefly exactly what you want the Court to do for you.

.

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 needed, you may attach no more

than fifteen additional pages. The form, however, must be completely filled in to the extent applicable.

Case 2:06-cv-00098-DGC--LOA Document 4 Filed 01/30/06 Page 19 of 19