Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_19-cv-05693/USCOURTS-azd-2_19-cv-05693-0/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 SC

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Isiah Romont Hill,

Plaintiff, 

v. 

Arizona Department of Corrections,

Defendant.

No. CV 19-05693-PHX-JAT (CDB)

ORDER

On August 20, 2019, Plaintiff Isiah Romont Hill, who is in the custody of the 

Arizona Department of Corrections (ADC), filed a “State Court Complaint” in Maricopa 

County Superior Court case #CV 2019-004926 against several Defendants, including 

ADC. (Doc. 1-3 at 3-6.)1 In his Complaint, Plaintiff asserted violations of his First through 

Fourteenth Amendment rights allegedly stemming from the use of excessive force and 

restrictions on seeing one of his children. The State of Arizona was served on October 30, 

2019.2 On November 27, 2019, the State and ADC removed the case to this Court based 

upon federal question subject matter jurisdiction. (Doc. 1.)

On December 5, 2019, Plaintiff filed a motion to strike the notice of removal 

(Doc. 4), which the Court construed as a motion to remand this case to state court. On 

1 The citation refers to the document and page number generated by the Court’s 

Case Management/Electronic Case Filing system.

2

 Although the State of Arizona was not a named Defendant, it was served with the 

Complaint and noted that to the extent Plaintiff sought relief against ADC, the State was 

the real party in interest. 

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December 9, 2019, Plaintiff filed two notices (Docs. 5 and 6.) On December 12, 2019, 

Defendant filed a response to Plaintiff’s motion to strike (Doc. 7). On December 18, 2019, 

Plaintiff filed a motion to proceed (Doc. 8) and a motion to suppress (Doc. 9). On January 

2, 2020, Plaintiff filed an objection to Prison Litigation Reform Act (PLRA) review 

(Doc. 10) and another notice (Doc. 11). On January 8, 2020, Plaintiff filed a motion to 

stay (Doc. 12), and on January 14, 2020, Plaintiff filed a motion for ruling on his motion 

to suppress (Doc. 13). 

In a January 28, 2020 Order, the Court overruled Plaintiff’s objection to PLRA 

review of his Complaint,3 denied his notices to the extent that any relief was sought and 

denied his motions (Doc. 14). The Court also dismissed the Complaint with leave to file a 

first amended complaint because it was not filed on the court-approved form. (Id.) The 

Court granted Plaintiff 30 days to file a first amended complaint using this Court’s 

approved form complaint for use by prisoners. (Id.) The Court expressly warned Plaintiff 

that failure to use the court-approved form complaint could result in an amended complaint 

being ordered stricken. (Id. at 3-4.) 

Plaintiff filed a motion for status seeking the status of his motion to suppress (Doc. 

15). The Court granted the motion for status to the extent that it informed him of the status 

of this action and his motion to suppress. Plaintiff then filed a “Motion to Strike/or 

Impeach Submitted Notice of Judged Fact Rule 201” (Doc. 18). In this motion, Plaintiff 

asked the Court to strike the removal of this action from the record, which the Court denied 

(Doc. 21). 

On February 20, 2020, Plaintiff filed a First Amended Complaint (Doc. 23) but did 

not use the court-approved form. Plaintiff also filed a “Motion of Notice of Adjudicated 

Fact Presented Rule of Evidence 201” (Doc. 24); a motion for entry of default judgment 

(Doc. 26); a motion to enforce 18 U.S.C. § 2518(9) (Doc. 27); and a motion to stay (Doc. 

28). The Court will dismiss the First Amended Complaint for failure to comply with court 

orders by using the court-approved form and will deny the motions. The Court will grant 

3

 See 28 U.S.C. § 1915A(a).

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Plaintiff an additional opportunity to file an amended complaint using the court-approved 

form.

I. Dismissal for Failure to Use the Court-Approved Form Complaint

Rule 3.4 of the Local Rules of Civil Procedure requires that all complaints must be 

filed on a court-approved form in accordance with the instructions provided with the 

forms. The Instructions for completing the court-approved form complaint state in relevant 

part that: 

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. 

(Instructions at 1).

The Instructions further provide that: 

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.

(Instructions, part C). 

Because Plaintiff filed this case in state court, he did not use this Court’s approved 

form complaint for use by prisoners. In its January 28, 2020 Order, the Court dismissed 

the Complaint with leave to file an amended complaint using the court-approved form

(Doc. 14). Although Plaintiff filed a First Amended Complaint, he did not use the courtCase 2:19-cv-05693-JAT--MTM Document 30 Filed 04/20/20 Page 3 of 18
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approved form. Accordingly, the Court will dismiss the First Amended Complaint for 

failure to comply with Court Orders. The Court will grant Plaintiff an additional 

opportunity to file an amended complaint on the court-approved form. If Plaintiff fails to 

comply, any amended complaint may be ordered stricken or dismissed and this case 

dismissed. 

II. Leave to Amend

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

for failure to comply with court orders by using the court-approved form complaint for use 

by prisoners in compliance with the Instructions. Within 30 days, Plaintiff may submit a 

second amended complaint to cure the deficiency 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 or dismiss 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).

III. Plaintiff’s Motions

As noted above, Plaintiff has filed a “Motion of Notice of Adjudicated Fact 

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Presented Rule of Evidence 201” (Doc. 24), a motion for entry of default judgment (Doc. 

26), a motion to enforce 18 U.S.C. § 2518(9) (Doc. 27), and a motion to stay (Doc. 28).

A. Motion of Adjudicated Fact

In this motion, Plaintiff refers to a case he filed in Maricopa County Superior Court, 

case #CV 19-004014, naming Charles Ryan and others as defendants. On January 3, 2020, 

the Superior Court granted the defendants’ motion to dismiss the case as barred by Arizona 

Revised Statutes §§ 31-201.01(L) and 12-821.01.4 Plaintiff apparently believes that he 

prevailed on a claim in the state court action or that dismissal of that action somehow 

violated double jeopardy. Whatever Plaintiff is attempting to assert as a basis for any relief 

fails because federal courts lack jurisdiction to review state court decisions. See Exxon 

Mobile Corp. v. Saudi Basic Industries Corp., 544 U.S. 280, 284 (2005). This motion will 

be denied to the extent that any relief is sought therein.

B. Motion for Entry of Default Judgment

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); 42 U.S.C. § 1997e(c). A defendant is not required to respond to such 

a complaint until ordered to do so by the Court following screening. Id. No Defendant in 

this case has been served or ordered to respond to the Complaint or First Amended 

Complaint. Further, entry of default has not been entered by the Court. Therefore, 

Plaintiff’s motion for entry of default judgment will be denied.

C. Motion to Enforce 18 U.S.C. § 2518(9)

Section 2518(9) of title 18 provides that:

The contents of any wire, oral, or electronic communication intercepted 

pursuant to this chapter or evidence derived therefrom shall not be received 

in evidence or otherwise disclosed in any trial, hearing, or other proceeding 

in a Federal or State court unless each party, not less than ten days before the 

trial, hearing, or proceeding, has been furnished with a copy of the court 

order, and accompanying application, under which the interception was 

4

 See http://www.courtminutes.maricopa.gov/viewerME.asp?fn=Civil/012020/ 

m8993998.pdf (last accessed Apr. 8, 2020). 

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authorized or approved. This ten-day period may be waived by the judge if 

he finds that it was not possible to furnish the party with the above 

information ten days before the trial, hearing, or proceeding and that the party 

will not be prejudiced by the delay in receiving such information.

Plaintiff states that he was subject to a wiretap in 2006, and implies that evidence 

therefrom was presented in his Maricopa County Superior Court criminal proceedings, case 

#CR2006-009614. Plaintiff claims that wiretap information cannot be disclosed in a 

federal court unless each party is provided at least ten days’ notice. As described in 

Plaintiff’s habeas corpus case, 

On October 6, 2006, Petitioner was indicted on more than 70 counts 

of various criminal offenses relating to the running of a prostitution 

enterprise, including counts of kidnapping, sexual assault and sexual abuse. 

On November 9, 2007, Petitioner pled guilty to two counts of Conspiracy to 

Illegally Control an Enterprise, a class 2 felony with one prior felony 

conviction (Counts 3, 4), one count of Unlawful Use of a Wire or Electronic 

Communication, a class 4 felony with one prior felony conviction (Count 

67), one count of Conspiracy (to commit burglary), a class 3 felony with one 

prior conviction (Count 81), one count of Kidnapping, a class 2 felony 

(Count 12), one count of Illegal Control of an Enterprise, a class 3 felony 

(Count 2), one count of Attempted Child Prostitution, a class 3 felony (Count 

35), and one count of Pandering, a class 5 felony (Count 75). Petitioner was 

subsequently sentenced to an aggregate prison sentence of 16 years, to be 

followed by a probationary term of five years once released from the 

Department of Corrections. 

Hill v. White, No. CV10-01339-PHX-GMS (D. Ariz. Nov. 24, 2010), Doc. 30 at 2.

Plaintiff fails to set forth any facts to support that any wiretap evidence was received 

in evidence or otherwise disclosed in any trial, hearing, or other proceeding in Federal or 

State court. But even if Plaintiff had, any alleged failure to comply with § 2518(9) should 

have been raised in Plaintiff’s criminal case or on review therefrom. For these reasons, 

Plaintiff’s motion will be denied.

D. Motion to Stay

Finally, Plaintiff has filed a motion to stay. Plaintiff seeks a stay until Defendants 

answer the Complaint. As discussed above, the Complaint was dismissed. Therefore, no 

answer has been, or will be, filed to the Complaint. Consequently, there is no basis to stay 

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this case and Plaintiff’s motion will be denied. 

IV. 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 “Strike”

Because the First Amended Complaint has been dismissed for failure to state a 

claim, if Plaintiff fails to file a second amended complaint correcting the deficiencies 

identified in this Order, the dismissal may count as a “strike” under the “3-strikes” 

provision of 28 U.S.C. § 1915(g). Under the 3-strikes provision, a prisoner may not bring 

a civil action or appeal a civil judgment in forma pauperis under 28 U.S.C. § 1915 “if the 

prisoner has, on 3 or more prior occasions, while incarcerated or detained in any facility, 

brought an action or appeal in a court of the United States that was dismissed on the 

grounds that it is frivolous, malicious, or fails to state a claim upon which relief may be 

granted, unless the prisoner is under imminent danger of serious physical injury.” 28 

U.S.C. § 1915(g). 

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, 963 F.2d 

at 1260-61 (a district court may dismiss an action for failure to comply with any order of 

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the Court).

IT IS ORDERED: 

(1) The First Amended Complaint (Doc. 23) is dismissed for failure to comply 

with Court Order to use the court-approved form complaint for use by prisoners. Plaintiff 

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

compliance with this Order.

(2) 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 with 

prejudice.

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

civil rights complaint by a prisoner. 

(4) Plaintiff’s “Motion of Notice of Adjudicated Fact Presented Rule of 

Evidence 201” (Doc. 24), motion for entry of default judgment (Doc. 26), motion to 

enforce 18 U.S.C. § 2518(9) (Doc. 27), and motion to stay (Doc. 28) are denied.

Dated this 20th day of April, 2020.

Case 2:19-cv-05693-JAT--MTM Document 30 Filed 04/20/20 Page 8 of 18
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.

Case 2:19-cv-05693-JAT--MTM Document 30 Filed 04/20/20 Page 12 of 18
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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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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COUNT II

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

.

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

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

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

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

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

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

citing legal authority or arguments.

.

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

.

5. Administrative Remedies.

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

your institution? G Yes G No

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

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

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

did not. 

.

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COUNT III

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

.

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

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

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

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

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

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

citing legal authority or arguments.

.

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

.

5. Administrative Remedies.

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

your institution? G Yes G No

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

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

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

did not. 

.

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

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E. REQUEST FOR RELIEF

State the relief you are seeking:

.

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

Executed on 

DATE SIGNATURE OF PLAINTIFF

___________________________________________

(Name and title of paralegal, legal assistant, or

other person who helped prepare this complaint)

___________________________________________

(Signature of attorney, if any)

___________________________________________

(Attorney=s address & telephone number)

ADDITIONAL PAGES

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

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

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

all pages.

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