Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_19-cv-05554/USCOURTS-azd-2_19-cv-05554-0/pdf.json

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

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WO MH

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Derek Anthony Higuera,

Plaintiff, 

v. 

City of Glendale, et al.,

Defendants.

No. CV 19-05554-PHX-MTL (JZB)

ORDER

On November 1, 2019, Plaintiff Derek Anthony Higuera, who is confined in a 

Maricopa County Jail, filed a pro se civil rights Complaint pursuant to 42 U.S.C. § 1983 

and an Application to Proceed In Forma Pauperis (Doc. 2). On November 8, 2019, Plaintiff 

filed a Motion for Legal Supplies (Doc. 5) and a Motion to Supplement the Complaint 

(Doc. 6). On November 15, 2019, Plaintiff filed a Motion for Appointment of Counsel 

(Doc. 7). On December 13, 2019, he filed a Motion to Amend the Complaint (Doc. 8). 

The Court will grant the Application to Proceed, grant the Motion to Amend and 

Motion to Supplement the Complaint in part, and deny without prejudice the Motion for 

Legal Supplies and Motion for Appointment of Counsel. Plaintiff will have 30 days to file 

an amended complaint that includes all allegations and claims.

I. Application to Proceed In Forma Pauperis and Filing Fee

The Court will grant Plaintiff’s Application to Proceed In Forma Pauperis. 28 

U.S.C. § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. 

§ 1915(b)(1). The Court will assess an initial partial filing fee of $8.81. The remainder of 

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the fee will be collected monthly in payments of 20% of the previous month’s income 

credited to Plaintiff’s trust account each time the amount in the account exceeds $10.00. 

28 U.S.C. § 1915(b)(2). The Court will enter a separate Order requiring the appropriate 

government agency to collect and forward the fees according to the statutory formula.

II. Motion for Legal Supplies

In his Motion for Legal Supplies, Plaintiff requests an “Authorized Legal Indigent 

Supply Package.” He claims that when he requested supplies from Maricopa County’s 

Inmate Legal Services (ILS), he was told to obtain them from his attorney. However, “the 

complaint in the USDC for Arizona is filed in forma pauperis and [Plaintiff has] no counsel 

representative or assi[s]tant of any kind to provide [the] materials” he seeks. According to 

Plaintiff, he lacks funds to purchase supplies “as of 10/28/2019” and is “very stressed at 

borrowing with interest just to proceed with [his] case work.” 

Pursuant to Maricopa County Sheriff’s Office Policy DP-6, inmates with less than 

five dollars in their inmate account who are representing themselves in suits against 

government entities over conditions of confinement or other civil rights issues are eligible 

to receive free writing materials on a bi-weekly basis.1 Although Plaintiff alleges that ILS

denied his request for supplies, it is not clear whether he advised ILS that he was seeking

supplies in connection with a pro se lawsuit concerning his conditions of confinement. Nor 

is it clear that he is financially qualified to obtain such assistance. Accordingly, Plaintiff’s 

Motion for Legal Supplies will be denied without prejudice.

III. Motion for Appointment of Counsel

In his Motion for Appointment of Counsel, Plaintiff requests that an attorney be 

appointed to represent him because he cannot afford to hire 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. 

1 See https://www.mcso.org/documents/Policy/Detention/DP-6.pdf (last visited Jan. 

29, 2020).

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

 Having considered both elements, it does not appear at this time that exceptional 

circumstances are present that would require the appointment of counsel in this case. 

Plaintiff is in no different position than many pro se prisoner litigants. Thus, the Court will 

deny without prejudice Plaintiff’s Motion for Appointment of Counsel.

IV. Motion to Supplement and Motion to Amend

In his Motion to Supplement, Plaintiff seeks permission to add certain allegations

to his Complaint. In his Motion to Amend, he seeks permission to name an additional 

Defendant—the Maricopa County Sheriff’s Office—through either supplementation or 

amendment. 

Under Rule 15(a)(1) of the Federal Rules of Civil Procedure, a party may amend its 

pleading once as a matter of course within: (A) 21 days after serving it; or (B) if the 

pleading is one to which a responsive pleading is required, 21 days after service of a 

responsive pleading or 21 days after service of a motion under Rule 12(b), (e), or (f), 

whichever is earlier. No Defendant has been served; accordingly, Plaintiff does not need 

leave of the Court to amend his Complaint to add new allegations or Defendants. In the 

interest of efficiency, however, the Court will grant the Motion to Amend and Motion to 

Supplement to the extent that Plaintiff shall have 30 days from the filing date of this Order 

to file an amended complaint that includes all his allegations and claims.2 In all other 

2

In filing in amended complaint, Plaintiff should be aware that the Maricopa County 

Sheriff’s Office is not a proper defendant because it is a “non-jural entity.” Melendres v. 

Arpaio, 784 F.3d 1254, 1260 (9th Cir. 2015) (citing Braillard v. Maricopa County, 232 

P.3d 1263, 1269 (Ariz. Ct. App. 2010)). 

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respects, the Motions will be denied. If Plaintiff fails to file an amended complaint within 

30 days, the Court will proceed to screen the original Complaint as filed. 

V. Leave to Amend

Within 30 days, Plaintiff may submit a first amended complaint that includes all his 

allegations and claims. The Clerk of Court will mail Plaintiff a court-approved form to use 

for filing a first amended complaint. If Plaintiff fails to use the court-approved form, the 

Court may strike the 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 “First 

Amended Complaint.” The first 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. Plaintiff may include only one claim per count.

A first amended complaint supersedes the original Complaint. Ferdik v. Bonzelet, 

963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner & Co., 896 F.2d 

1542, 1546 (9th Cir. 1990). After amendment, the Court will treat the original Complaint 

as nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised in the 

original Complaint and that was voluntarily dismissed or was dismissed without prejudice 

is waived if it is not alleged in a first amended complaint. Lacey v. Maricopa County, 693 

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

If Plaintiff files an amended complaint, Plaintiff must write short, plain statements 

telling the Court: (1) the constitutional right Plaintiff believes was violated; (2) the name 

of the Defendant who violated the right; (3) exactly what that Defendant did or failed to 

do; (4) how the action or inaction of that Defendant is connected to the violation of 

Plaintiff’s constitutional right; and (5) what specific injury Plaintiff suffered because of 

that Defendant’s conduct. See Rizzo v. Goode, 423 U.S. 362, 371-72, 377 (1976).

Plaintiff must repeat this process for each person he names as a Defendant. If 

Plaintiff fails to affirmatively link the conduct of each named Defendant with the specific 

injury suffered by Plaintiff, the allegations against that Defendant will be dismissed for 

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failure to state a claim. Conclusory allegations that a Defendant or group of 

Defendants has violated a constitutional right are not acceptable and will be 

dismissed.

VI. Warnings

A. Release

If Plaintiff is released while this case remains pending, and the filing fee has not 

been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court 

that he intends to pay the unpaid balance of his filing fee within 120 days of his release or 

(2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may 

result in dismissal of this action.

B. Address Changes

Plaintiff must file and serve a notice of a change of address in accordance with Rule 

83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion for other 

relief with a notice of change of address. Failure to comply may result in dismissal of this 

action.

C. Possible Dismissal

If Plaintiff fails to timely comply with every provision of this Order, including these 

warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d 

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

the Court).

IT IS ORDERED: 

(1) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 2) is granted.

(2) As required by the accompanying Order to the appropriate government 

agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing fee 

of $8.81.

(3) Plaintiff’s Motion for Legal Supplies (Doc. 5) and Motion for Appointment 

of Counsel (Doc. 7) are denied without prejudice.

. . . .

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(4) Plaintiff’s Motion to Supplement (Doc. 6) and Motion for Leave to Amend 

(Doc. 8) are granted insofar as Plaintiff has 30 days from the date this Order is filed to file 

a first amended complaint in compliance with this Order. In all other respects, the Motions 

are denied.

(5) If Plaintiff fails to file an amended complaint within 30 days, this case will 

proceed upon Plaintiff’ s original Complaint.

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

civil rights complaint by a prisoner.

Dated this 29th day of January, 2020.

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Revised 3/11/16 1

Instructions for a Prisoner Filing a Civil Rights Complaint 

in the United States District Court for the District of Arizona

1. Who May Use This Form. The civil rights complaint form is designed to help incarcerated 

persons prepare a complaint seeking relief for a violation of their federal civil rights. These 

complaints typically concern, but are not limited to, conditions of confinement. This form

should not be used to challenge your conviction or sentence. If you want to challenge a state 

conviction or sentence, you should file a petition under 28 U.S.C. ' 2254 for a writ of habeas 

corpus by a person in state custody. If you want to challenge a federal conviction or sentence, you 

should file a motion under 28 U.S.C. § 2255 to vacate sentence in the federal court that entered the 

judgment. 

2. The Form. Local Rule of Civil Procedure (LRCiv) 3.4(a) provides that complaints by 

incarcerated persons must be filed on the court-approved form. The form must be typed or 

neatly handwritten. The form must be completely filled in to the extent applicable. All questions 

must be answered clearly and concisely in the appropriate space on the form. If needed, you may 

attach additional pages, but no more than fifteen additional pages, of standard letter-sized 

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

you do not fill out the form properly, you will be asked to submit additional or corrected 

information, which may delay the processing of your action. You do not need to cite law. 

3. Your Signature. You must tell the truth and sign the form. If you make a false statement of a 

material fact, you may be prosecuted for perjury.

4. The Filing and Administrative Fees. The total fees for this action are $400.00 ($350.00 filing 

fee plus $50.00 administrative fee). If you are unable to immediately pay the fees, you may 

request leave to proceed in forma pauperis. Please review the “Information for Prisoners Seeking 

Leave to Proceed with a (Non-Habeas) Civil Action in Federal Court In Forma Pauperis Pursuant 

to 28 U.S.C. ' 1915” for additional instructions.

5. Original and Judge=s Copy. You must send an original plus one copy of your complaint and 

of any other documents submitted to the Court. You must send one additional copy to the Court if 

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

identical to the original. Copies may be legibly handwritten. This section does not apply to 

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

electronic filing.

6. Where to File. You should file your complaint in the division where you were confined 

when your rights were allegedly violated. See LRCiv 5.1(a) and 77.1(a). If you were confined 

in Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. If you were 

confined in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott Division. 

If you were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file in the 

Tucson Division. Mail the original and one copy of the complaint with the $400 filing and 

administrative fees or the application to proceed in forma pauperis to:

Case 2:19-cv-05554-MTL--JZB Document 9 Filed 01/29/20 Page 7 of 16
2

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-05554-MTL--JZB Document 9 Filed 01/29/20 Page 10 of 16
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.

Case 2:19-cv-05554-MTL--JZB Document 9 Filed 01/29/20 Page 16 of 16