Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_05-cv-03891/USCOURTS-azd-2_05-cv-03891-0/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 42:1983 Prisoner Civil Rights

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JDDL-K

WO LMH

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Gregory Gammage, 

Plaintiff, 

vs.

Phoenix Police Dep’t, et al., 

Defendants. 

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No. CV 05-3891-PHX-MHM (LOA)

ORDER

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

in the Fourth Avenue 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 granted. Pursuant to 28 U.S.C.

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

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 appropriate 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 appropriate 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).

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

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

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release. If Plaintiff fails to pay the remainder of the filing fee within 120 days of the 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 thereof if 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). 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 district 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). Plaintiff’s Complaint will be

dismissed for failure to state a claim, with leave to amend because the complaint may

possibly be saved by amendment.

C. Complaint.

Plaintiff sues the Phoenix Police Department and two of its undercover officers named

Bradley Geis and Delbert Wheeler. In Count I of the Complaint, Plaintiff alleges that

Defendants violated his rights by lying about the reasons for arresting him, regarding his

failure to change his official address and that he had an outstanding warrant. Plaintiff also

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contends that he was not given medical attention for an injured leg when he was arrested,

despite his request.

 In Count II, Plaintiff alleges that the jail conditions are inhumane. He does not

describe what makes the conditions intolerable. He simply states that Defendants violated

his right to be free from cruel and unusual punishment.

1. Phoenix Police Department

A municipality such as the Phoenix Police Department may not be held liable unless

its policy or custom caused the constitutional injury. See Leatherman v. Tarrant County

Narcotics Intelligence and Coordination Unit, 507 U.S. 163, 166 (1993); Monell v.

Department of Social Services, 436 U.S. 658, 694 (1978). Thus, a § 1983 claim against a

municipal defendant “cannot succeed as a matter of law” unless the plaintiff: (1) contends

that the municipal defendant maintains a policy or custom pertinent to the plaintiff’s alleged

injury; and (2) explains how such policy or custom caused the plaintiff’s injury. Sadoski v.

Mosley, 435 F.3d 1071, 1079-80 (9th Cir. 2006) (affirming dismissal of a municipal

defendant pursuant to FED.R.CIV. P. 12(b)(6)). Plaintiff has not set forth any allegations to

satisfy this standard.

2. “False arrest”

Plaintiff alleges that his arrest was based on false reasons. Currently, a criminal

action, presumably arising from the arrest, is pending in the Maricopa County Superior

Court, Matter No. CR2005-010307, and trial has been set for May 15, 2006. Plaintiff’s false

arrest claim is premature.

When a prisoner challenges the validity of his confinement, his sole federal remedy

is a writ of habeas corpus. Preiser v. Rodriguez, 411 U.S. 475, 500 (1973). For civil rights

claims brought in § 1983 actions that also challenge the validity of confinement, the Supreme

Court announced a “favorable termination rule” as follows:

In order to recover damages for allegedly unconstitutional conviction or

imprisonment, or for other harm caused by action whose unlawfulness would

render a conviction or sentence invalid, a § 1983 plaintiff must prove that the

conviction or sentence has been reversed on direct appeal, expunged by

executive order, declared invalid by a state tribunal authorized to make such

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determination, or called into question by a federal court’s issuance of a writ of

habeas corpus . . . 

Heck v. Humphrey, 512 U.S. 477, 486-87 (1994). Without such a showing of a “favorable

termination,” the person’s cause of action under § 1983 has not yet accrued. Id. at 489.

Thus, if a judgment in favor of the plaintiff would necessarily imply that invalidity of his

conviction or sentence, the complaint must be dismissed. Id. at 487.

The Ninth Circuit Court of Appeals has found that “[t]here is no question” that the

“favorable termination” rule bars a convicted Plaintiff’s claim that defendants lacked

probable cause to arrest and that defendants brought unfounded charges. Smithart v. Towery,

79 F.3d 951, 952 (9th Cir. 1996). Wrongful arrest and bringing false charges could not have

occurred unless the plaintiff were innocent of the crimes for which he was convicted.

Guerrero v. Gates, ___ F.3d ___, 2006 WL 760239, at *2 (9th Cir. March 27, 2006). 

The Ninth Circuit Court of Appeals has also held that the concerns in Heck apply preconviction as well as post-conviction. Harvey v. Waldron, 210 F.3d 1008, 1014-15 (2005).

“We agree with [six other circuit courts of appeal] and hold that Heck applies to pending

criminal charges, and that a claim, if successful, would necessarily imply the invalidity of a

conviction in a pending criminal prosecution, does not accrue so long as the potential for a

conviction in the pending criminal prosecution continues to exist.” Id. at 1014. 

Plaintiff’s claim that he was falsely arrested is therefore premature. His claim that he

was arrested without any basis necessarily implies the invalidity of any conviction that might

potentially result from the pending charges. Plaintiff can bring a § 1983 claim only if the

charges against him are dismissed, or if he is convicted and has the conviction set aside.

Until that time, his § 1983 action is premature. The claim will be dismissed without

prejudice.

3. Lack of medical attention upon arrest

Plaintiff alleges that he did not receive medical attention for an injured leg upon his

arrest, despite his request. He asserts this allegation as a claim of injury from the false arrest,

not as a separate count for relief. See Compl. at 4. It therefore appears that Plaintiff does not

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intend to assert a separate claim based on these allegations. Even if he did, Plaintiff’s

allegation is insufficient to state a claim.

The Due Process Clause requires the government to provide medical care to persons

who have been injured during their arrest. City of Revere v. Massachusetts Gen. Hosp., 463

U.S. 239, 244 (1983); Maddox v. City of Los Angeles, 792 F.2d 1408, 1415 (9th Cir. 1986).

When a person is arrested and his liberty is so restrained that he cannot care for himself, the

arresting officer has a duty to assume some responsibility for the person’s safety and wellbeing. DeShaney v. Winnebago County Dep’t of Social Serv., 489 U.S. 189, 199-200

(1989). A due process a claim by a pretrial detainee, however, requires a showing of some

harm or disability. See Bell v. Wolfish, 441 U.S. 520, 538 (1979); see also Demery v.

Arpaio, 378 F.3d 1020, 1029 (9th Cir. 2004), cert. denied, 125 S. Ct. 2961 (2005). Plaintiff

has not alleged that he was harmed by the lack of medical care at the time of his arrest. His

allegations are too sparse to state a claim. This claim will be dismissed without prejudice.

4. Jail conditions

Plaintiff alleges that he was subjected to inhumane jail conditions. First, he has failed

to describe how the jail conditions were inhumane or how he was harmed by them. For this

reason alone, he fails to state a claim. Second, the allegations are not connected to any of the

Defendants, who are a police department and police officer. These city Defendants typically

are not responsible for the conditions of county jail. Plaintiff therefore fails to state a claim.

D. 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. Plaintiff may amend his Complaint to cure the

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 the court-approved form and may

not incorporate 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. 

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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.), cert. denied, 506 U.S. 915 (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).

E. Address Changes.

In the 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. Plaintiff is again reminded

that 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 parties. 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 pursuant to Rule 41(b) of the Federal Rules of Civil

Procedure.

F. 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 notice. 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

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dismissal of this action will count as a “strike” under the “three strikes” 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 obligated to 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 the appropriate 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 notice to Plaintiff, if Plaintiff fails to file an amended complaint

within thirty (30) days of the date this Order is filed. Upon entry of judgment, the Clerk shall

make an entry on the docket in this matter 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 LRCiv 3.5(a), 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 to comply with this requirement may result in the pleading or document

being stricken without further notice to Plaintiff.

(6) The Clerk of Court is directed to provide to Plaintiff a current court-approved

form for filing a civil rights complaint by a prisoner.

DATED this 8th day of June, 2006.

Case 2:05-cv-03891-MHM--LOA Document 3 Filed 06/13/06 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 2:05-cv-03891-MHM--LOA Document 3 Filed 06/13/06 Page 8 of 19
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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

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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

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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

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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.

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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: .

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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: 

.

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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 2:05-cv-03891-MHM--LOA Document 3 Filed 06/13/06 Page 15 of 19
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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 2:05-cv-03891-MHM--LOA Document 3 Filed 06/13/06 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 2:05-cv-03891-MHM--LOA Document 3 Filed 06/13/06 Page 17 of 19
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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.)

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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 2:05-cv-03891-MHM--LOA Document 3 Filed 06/13/06 Page 19 of 19