Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_15-cv-00590/USCOURTS-azd-2_15-cv-00590-0/pdf.json

Nature of Suit Code: 555
Nature of Suit: Prisoner - Prison Condition
Cause of Action: 28:1441 Petition for Removal- Civil Rights Act

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Benjamin Freeman, 

Plaintiff, 

 v. 

Joseph M. Arpaio, et al., 

Defendants. 

No. CV 15-0590-PHX-SMM (MHB) 

 O R D E R 

Plaintiff Benjamin Freeman, who is confined in the Fourth Avenue Jail in Phoenix 

Arizona, filed a pro se civil rights Complaint in Maricopa County Superior Court, case# 

CV15-003568, on March 13, 2015. (Doc. 1-2, Ex.2.) In his Complaint, Plaintiff alleged 

violations of his federal constitutional rights. Plaintiff sued Maricopa County Sheriff 

Joseph M. Arpaio, and the following staff of the Maricopa County Sheriff’s Office 

(MCSO): Inmate Legal Services (ILS) Supervisor C. Lillie; and Detention Officers John 

or Jane Does B1328 and B0429. Further, although not expressly identified as 

Defendants, Plaintiff included allegations against Sergeant Haider, Lieutenants Beyerle 

and A4226, L. Estrada, notary publics C. Gerdes and R.A. Perry, and Maricopa County. 

Plaintiff issued summons to Maricopa County, Arpaio, Lillie, Doe #B0429, Gerdes, 

Haider, Beyerle, Doe #B1328, Perry, and Estrada. 

Defendants Arpaio, Lillie, Beyerle, Gerdes, Estrada, Perry, Doe B0429, Doe 

B1328, and Haider were served with the Complaint on March 17, 2015, and Maricopa 

County was served on March 25, 2015. On April 1, 2015, Maricopa County removed the 

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case to this Court based on federal question jurisdiction. (Doc. 1-3.) Plaintiff then filed a 

motion to invoke the imminent danger exception, motion to remand, and motion for 

appointment of counsel, to which the Defendants have responded and Plaintiff has 

replied. (Doc. 3-11.) 

The Complaint facially supports that subject matter jurisdiction is proper in federal 

court and that the case was timely removed. 28 U.S.C. § 1446(b). Therefore, the Court 

will deny Plaintiff’s motion to remand. The Court will also deny Plaintiff’s motion to 

invoke imminent danger exception under 28 U.S.C. § 1915(g), because this case was not 

brought in federal court, but was instead removed to federal court, and the Court will 

deny Plaintiff’s motion to appoint counsel. The Court will dismiss the Complaint with 

leave to amend using the Court-approved form complaint. 

I. Removal to Federal Court was Proper 

A defendant may remove any civil action brought in state court over which the 

federal court would have original jurisdiction. 28 U.S.C. §1441(a). That is, a civil action 

that could have originally been brought in federal court may be removed from state to 

federal court. Caterpillar Inc. v. Williams, 482 U.S. 386, 392 (1987). A federal court has 

original jurisdiction “of all civil actions arising under the Constitution, laws, or treaties of 

the United States.” 28 U.S.C. § 1331. 

 The Complaint in this case facially supports that subject matter jurisdiction exists 

in federal court because Plaintiff alleges violation of his federal constitutional rights. 28 

U.S.C. §§ 1441. Further, the case was timely removed. 28 U.S.C. § 1446(b). 

Accordingly, the Court has subject matter jurisdiction and the Court will deny Plaintiff’s 

motion to remand.1

 

1

 Plaintiff seeks remand on the basis that he applied for deferral or waiver of court fees or costs and did not seek to proceed in forma pauperis in state court. Plaintiff, who 

has accumulated three strikes under the Prison Litigation Reform Act (PLRA), appears to fear that removal of his case to federal court will violate 28 U.S.C. § 1915(g) and require him to pay the filing and administrative fees. For those reasons, Plaintiff also attempts to invoke § 1915(g)’s imminent danger exception. Section 1915(g) applies to cases or appeals brought in federal court, not those removed from state to federal court by a defendant. In such instances, a plaintiff is not required to meet the imminent danger exception, nor will a plaintiff in such circumstances be obligated to pay the filing and 

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II. Failure to Use the Court-Approved Form Complaint 

Local Rule 3.4 requires prisoners to use a court-approved form complaint. As 

noted above, Plaintiff used a state court form complaint. The Court will dismiss the 

Complaint with leave to file a first amended complaint using this District’s approved 

form. The Court describes the relevant standards for the type of claims that Plaintiff 

appears to be attempting to bring. 

III. 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 

 administrative fees for a removed case. Instead, the removing defendant must pay those fees. See 28 U.S.C. § 1914(a). Therefore, Plaintiff’s motions to remand and to invoke 

the imminent danger exception will be denied. 

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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 

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. 

IV. Complaint 

Plaintiff ostensibly appears to be attempting to allege a claim for violation of the 

Establishment Clause of the First Amendment and denial of access to the court. He 

alleges that he was a pretrial detainee at relevant times and that he is an atheist. Plaintiff 

further alleges the following: on September 24, 2013, Plaintiff was arrested by 

Scottsdale police and his 2000 Mercedes Benz was seized. At the Fourth Avenue Jail, 

American flag decals are present in every cell. Further, patriotic songs with religious 

overtones, specifically the national anthem, Amazing Grace, My Country Tis of Thee, 

God Bless America, and the 23rd Psalm, are played every morning and evening on the 

Jail’s televisions. Plaintiff contends that the presence of the flag decals and the repeated 

broadcasts of the patriotic/religious music has caused him to suffer nightmares 

concerning torture of women and children. He further contends that the religious 

overtones of the music infringe his right to be free from indoctrination in the Christian, or 

other, religion. Plaintiff also asserts that ILS staff failed to provide him case law and 

statutes, and that he was refused services of a notary public to contest the civil forfeiture 

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proceedings concerning the 2000 Mercedes Benz seized from him. 

V. Standard to State a Claim Under § 1983

 To prevail in a § 1983 claim, a plaintiff must show that (1) acts by the defendants 

(2) under color of state law (3) deprived him of federal rights, privileges or immunities 

and (4) caused him damage. Thornton v. City of St. Helens, 425 F.3d 1158, 1163-64 (9th 

Cir. 2005) (quoting Shoshone-Bannock Tribes v. Idaho Fish & Game Comm’n, 42 F.3d 

1278, 1284 (9th Cir. 1994)). In addition, a plaintiff must allege that he suffered a specific 

injury as a result of the conduct of a particular defendant and he must allege an 

affirmative link between the injury and the conduct of that defendant. Rizzo v. Goode, 

423 U.S. 362, 371-72, 377 (1976). 

 To state a claim against a defendant, “[a] plaintiff must allege facts, not simply 

conclusions [to] show that an individual was personally involved in the deprivation of his 

civil rights.” Barren v. Harrington, 152 F.3d 1193, 1194 (9th Cir. 1998). For an 

individual to be liable in his official capacity, a plaintiff must allege injuries resulting 

from a policy, practice, or custom of the agency over which that individual has final 

policy-making authority. See Cortez v. County of Los Angeles, 294 F.3d 1186, 1188 (9th 

Cir. 2002). Further, there is no respondeat superior liability under §1983, so a 

defendant’s position as the supervisor of someone who allegedly violated a plaintiff’s 

constitutional rights, absent more, does not make him liable. Monell v. Dep’t of Soc. 

Servs., 436 U.S. 658, 691 (1978); Taylor v. List, 880 F.2d 1040, 1045 (9th Cir. 1989). A 

supervisor in his personal capacity, “is only liable for constitutional violations of his 

subordinates if the supervisor participated in or directed the violations, or knew of the 

violations and failed to act to prevent them.” Taylor, 880 F.2d at 1045. In addition, 

where a defendant’s only involvement in allegedly unconstitutional conduct is the denial 

of administrative grievances, the failure to intervene on a prisoner’s behalf to remedy the 

alleged unconstitutional behavior does not amount to active unconstitutional behavior for 

purposes of § 1983. See Shehee v. Luttrell, 199 F.3d 295, 300 (6th Cir. 1999); accord 

Proctor v. Applegate, 661 F.Supp.2d 743, 765 (W.D. Mich. 2009); Stocker v. Warden, 

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No. 1:07-CV-00589, 2009 WL 981323, at *10 (E.D. Cal. Apr. 13, 2009); Mintun v. 

Blades, No. CV-06-139, 2008 WL 711636, at *7 (D. Idaho Mar. 14, 2008); see also

Gregory v. City of Louisville, 444 F.3d 725, 751 (6th Cir. 2006) (a plaintiff must allege 

that a supervisor defendant did more than play a passive role in an alleged violation or 

mere tacit approval thereof; a plaintiff must allege that the supervisor defendant somehow 

encouraged or condoned the actions of their subordinates). 

A. Religious Claim 

Plaintiff appears in part to be attempting to allege an Establishment Clause claim 

under the First Amendment. The Establishment Clause of the First Amendment, which is 

applicable to the States, Community House, Inc. v. City of Boise, 623 F.3d 945, 970 (9th 

Cir. 2010), provides that “Congress shall make no law respecting an establishment of 

religion.” U.S. Const. amend. I; Lee v. Weisman, 505 U.S. 577, 580 (1992). Thus, the 

Establishment Clause bars governmental approval or disapproval of a particular religion 

or belief. Church of the Lukumi Babalu Aye, Inc. v. City of Hialeah, 508 U.S. 520, 532 

(1993). The basic test for Establishment Clause violations is set out in Lemon v. 

Kurtzman, 403 U.S. 602, 612-13, (1971); to avoid violating the Establishment Clause, 

government acts (1) must have a “secular legislative purpose,” (2) must not have a 

“principal or primary effect” that either “advances [or] inhibits religion,” and (3) must not 

foster “an excessive government entanglement” with religion. Inouye v. Kemna, 504 

F.3d 705, 713 (9th Cir. 2007). 

B. Access to the Court Claim 

Plaintiff also appears to be attempting to assert a denial of access to the court. The 

right of meaningful access to the courts prohibits officials from actively interfering with 

inmates’ attempts to prepare or file legal documents. Lewis v. Casey, 518 U.S. 343, 350 

(1996). The right of access to the courts is only a right to bring petitions or complaints to 

federal court and not a right to discover such claims or even to ligate them effectively 

once filed with a court. Id. at 354. The right “guarantees no particular methodology but 

rather the conferral of a capability–the capability of bringing contemplated challenges to 

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sentences or conditions of confinement before the courts.” Id. at 356. 

 As a matter of standing, for an access-to-courts claim, a plaintiff must show that 

he suffered an “actual injury” with respect to contemplated litigation. Id. at 349. To 

show actual injury with respect to contemplated litigation, the plaintiff must demonstrate 

that the defendants’ conduct frustrated or impeded him from bringing to court a 

nonfrivolous claim that he wished to present. Id. at 352-53. 

 “[T]he injury requirement is not satisfied by just any type of frustrated legal 

claim.” Id. at 354. The right of access to the courts “does not guarantee inmates the 

wherewithal to transform themselves into litigating engines capable of filing everything 

from shareholder derivative actions to slip-and-fall claims.” Id. at 355. The nonfrivolous 

claim must be a direct or collateral attack on the inmate’s sentence or a challenge to the 

conditions of his confinement. Id. “Impairment of any other litigating capacity is simply 

one of the incidental (and perfectly constitutional) consequences of conviction and 

incarceration.” Id. (emphasis in original). 

VI. Motion for Appointment of Counsel 

Plaintiff seeks the appointment of counsel based on his indigence, lack of legal 

training and limited access to legal resources, complexity of the issues, need for expert 

testimony, and his unsuccessful attempts to find pro bono 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 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. 

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

 Having considered the above elements, it does not appear at this time that 

exceptional circumstances are present that require the appointment of counsel in this 

case. Plaintiff is in no different position than many pro se prisoner litigants. Therefore, 

the Court will deny without prejudice Plaintiff’s motion for appointment of 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

 Plaintiff must serve Defendants, or counsel if an appearance has been entered, a 

copy of every document that he files. Fed. R. Civ. P. 5(a). Each filing must include a 

certificate stating that a copy of the filing was served. Fed. R. Civ. P. 5(d). Also, 

Plaintiff must submit an additional copy of every filing for use by the Court. See LRCiv 

5.4. Failure to comply may result in the filing being stricken without further notice to 

Plaintiff. 

D. 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 v. 

Bonzelet, 963 F.2d 1258, 1260-61 (9th Cir. 1992) (a district court may dismiss an action 

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for failure to comply with any order of the Court). 

IT IS ORDERED: 

 (1) Plaintiff’s motions to remand, invoke the imminent danger exception, and 

appoint counsel are denied. (Doc. 3, 4, 5.) 

(2) The Complaint (Doc. 1) is dismissed for failure to use the court-approved 

form. Plaintiff has 30 days from the date this Order is filed to file a first amended 

complaint in compliance with this Order. 

 (3) 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. 

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

civil rights complaint by a prisoner. 

 DATED this 2nd day of June, 2015. 

Honorable Stephen M. McNamee

Senior United States District Judge

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Revised 3/9/07 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 Fee. The filing fee for this action is $350.00. If you are unable to immediately

pay the filing fee, 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 $350 filing

fee or the application to proceed in forma pauperis to:

Case 2:15-cv-00590-SMM--MHB Document 13 Filed 06/03/15 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 courtapproved 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-00590-SMM--MHB Document 13 Filed 06/03/15 Page 11 of 19
3

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.

Case 2:15-cv-00590-SMM--MHB Document 13 Filed 06/03/15 Page 13 of 19
Revised 3/9/07 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: .

Case 2:15-cv-00590-SMM--MHB Document 13 Filed 06/03/15 Page 14 of 19
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:

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.

Case 2:15-cv-00590-SMM--MHB Document 13 Filed 06/03/15 Page 15 of 19
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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. 

.

Case 2:15-cv-00590-SMM--MHB Document 13 Filed 06/03/15 Page 16 of 19
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. 

.

Case 2:15-cv-00590-SMM--MHB Document 13 Filed 06/03/15 Page 17 of 19
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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.

Case 2:15-cv-00590-SMM--MHB Document 13 Filed 06/03/15 Page 18 of 19
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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 2:15-cv-00590-SMM--MHB Document 13 Filed 06/03/15 Page 19 of 19