Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_07-cv-00379/USCOURTS-azd-2_07-cv-00379-0/pdf.json

Parties Involved:
Phoenix Memorial Hospital
Defendant
Laura Ann Rogers
Plaintiff

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JDDL-K

RP

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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Laura Ann Rogers, 

Plaintiff, 

vs.

Phoenix Memorial Hospital, 

Defendant. 

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No. CV 07-379-PHX-DGC (DKD)

ORDER

On February 20, 2007, Plaintiff Laura Ann Rogers, who is confined in the Maricopa

County Estrella Jail, filed a pro se civil rights Complaint (Doc. #1) pursuant to 42 U.S.C.

§ 1983. Plaintiff did not pay the $350.00 civil action filing fee but filed an uncertified

Application to Proceed In Forma Pauperis. 

By Order filed February 27, 2007 (Doc. #3), the Court denied Plaintiff's Application

to Proceed In Forma Pauperis without prejudice and gave Plaintiff 30 days from the filing

date of the Order to either pay the $350.00 filing fee or file a completed Application to

Proceed In Forma Pauperis and a six-month trust account statement.

On March 19, 2007, Plaintiff filed a "Motion - Request for Additional Time" (Doc.

#4). By Order filed March 23, 2007 (Doc. #5), Plaintiff's Motion was granted and Plaintiff

was given 30 days from the filing date of the Order to either pay the $350.00 filing fee or file

a new Application to Proceed In Forma Pauperis and a six-month trust account statement.

Unbeknownst to the Court, at the time the Court's March 23, 2007 Order was filed,

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Plaintiff had already filed a new Application to Proceed In Forma Pauperis and a six-month

trust account statement (Doc. #6) on March 22, 2007. On May 11, 2007, the Clerk of Court

inadvertently entered a judgement of dismissal of the Complaint and this action (Doc. #8)

because Plaintiff had not paid the $350.00 filing fee or filed a new Application to Proceed

In Forma Pauperis and a six-month trust account statement in response to the Court's March

23, 2007 Order. 

I. Motion to Reconsider 

On May 31, 2007, Plaintiff filed a "Motion to reconsider case closed" (Doc. #9), in

which Plaintiff states that she cannot find where she failed to comply with this Court's orders.

For good cause shown, Plaintiff's Motion will be granted and the Court will direct the Clerk

of Court to vacate the judgment entered on May 11, 2007 and to reopen this action. 

II. Application to Proceed In Forma Pauperis and Filing Fee

Plaintiff’s Application to Proceed In Forma Pauperis (Doc. #6) will be granted. 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 $11.56. 28 U.S.C.

§ 1915(b)(1). The remainder of the fee will be collected monthly in payments of 20% of the

previous month’s income 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. 

III. Statutory Screening of Prisoner Complaints

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

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

§ 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff has raised

claims that are legally frivolous or malicious, that fail to state a claim upon which relief may

be granted, or that seek monetary relief from a defendant who is immune from such relief.

28 U.S.C. § 1915A(b)(1), (2). If the Court determines that a pleading could be cured by the

allegation of other facts, a pro se litigant is entitled to an opportunity to amend a complaint

before dismissal of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000)

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(en banc).

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

of advice “would undermine 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 the court was required to inform a 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.

IV. Complaint

Plaintiff alleges two counts in her Complaint. In Count I, Plaintiff claims that her

Fourth Amendment rights were violated when she was held down against her will by

Emergency Room staff at Phoenix Memorial Hospital while they did a full cavity search of

her vagina without probable cause. In Count II, Plaintiff claims that her Fourth Amendment

rights were violated when she was held against her will by Emergency Room staff at Phoenix

Memorial Hospital to do a cavity search and an unauthorized "cath[et]er." Named as

Defendant in the Complaint is the Phoenix Memorial Hospital. Plaintiff seeks monetary

damages and victim/rape awareness training for Defendant.

V. Improper Defendant

To state a claim under 42 U.S.C. § 1983, Plaintiff must allege: (1) the conduct

complained of was committed by a person acting under color of state law; and (2) the

conduct deprived the Plaintiff of a constitutional right. Balisteri v. Pacifica Police Dep't, 901

F.2d 696, 699 (9th Cir. 1988). Defendant Phoenix Memorial Hospital appears to be a private

actor that was not acting under color of state law. 

Furthermore, there is no liability under 42 U.S.C. § 1983 based on a theory of

respondeat superior. Monell v. New York City Dept. of Social Services, 436 U.S. 658, 691

(1978); West v. Atkins, 487 U.S. 42, 54 n.12 (1988); Ybarra v. Reno Thunderbird Mobile

Home Village, 723 F.2d 675, 680-81 (9th Cir. 1984). A private corporation can be found

liable in an action pursuant to 42 U.S.C. § 1983 if it is acting under color of state law and the

constitutional deprivations resulted from a policy, custom, or practice of the private

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corporation. See Robinson v. City of San Bernadino Police Department, 992 F.Supp. 1198,

1204 (C.D.Cal. 1998). Because there is no liability under 42 U.S.C. § 1983 based on a

theory of respondeat superior, Defendant cannot be held liable simply because Emergency

Room staff were employed by the Hospital. Nor does Plaintiff claim that her injuries

resulted from a policy, custom, or practice of Phoenix Memorial Hospital. 

Accordingly, Phoenix Memorial Hospital is not a proper Defendant to this action and

is subject to dismissal without prejudice from this action for failure to state a claim upon

which relief may be granted.

VI. Leave to Amend

Although pro se pleadings are liberally construed, Haines v. Kerner, 404 U.S. 519 (1972),

conclusory and vague allegations will not support a cause of action. Ivey v. Board of Regents of the

University of Alaska, 673 F.2d 266 (9th Cir. 1982); Rhodes v. Robinson, 612 F.2d 766, 772 (3rd.

Cir. 1979). Further, a liberal interpretation of a civil rights complaint may not supply essential

elements of the claim that were not initially pled. Ivey, 673 F.2d at 268.

Because no Defendant now remains, Plaintiff’s Complaint will be dismissed for

failure to state a claim upon which relief may be granted. Within 30 days, Plaintiff may

submit a first amended complaint to cure the deficiencies outlined above. The Clerk of Court

will mail Plaintiff a court-approved form to use for 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 an original complaint as

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

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complaint is waived if it is not raised in a first amended complaint. King v. Atiyeh, 814 F.2d

565, 567 (9th Cir. 1987).

VII. Motion for Copy of Complaint

On March 27, 2007, Plaintiff filed a "Motion To Request A Copy of the Complaint"

(Doc. #7). In light of the dismissal of the Complaint with leave to amend, Plaintiff's Motion

will be denied.

VIII. Warnings

A. Release

Plaintiff must pay the unpaid balance of the filing fee within 120 days of her release.

Also, within 30 days of her release, Plaintiff must either (1) notify the Court that she intends

to pay the balance or (2) show good cause, in writing, why she cannot. Failure to comply

may result in dismissal.

B. Address Changes

Plaintiff must file and serve a notice of a change of address 10 days before the move

is effective, if practicable. See LRCiv 83.3(d). Plaintiff must not include a motion for other

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

C. Copies

Plaintiff must submit an additional copy of every document that she files for use by

the Court. See LRCiv 5.4. Failure to comply may result in the filing being stricken without

further notice to Plaintiff.

D. Possible “Strike”

Because the Complaint has been dismissed for failure to state a claim, if Plaintiff fails

to file an amended complaint correcting the deficiencies identified in this Order, the

dismissal will 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,

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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). 

E. Possible Dismissal

Plaintiff is warned that failure to timely comply with every provision of this Order,

including these warnings, may result in dismissal of 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 "Motion to reconsider case closed" (Doc. #9) is granted, the

judgment entered in this action on May 11, 2007 (Doc. #8) is vacated, and the Clerk or Court

must reopen this action.

(2) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. #6) is granted.

(3) 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 $11.56.

(4) Plaintiff's "Motion To Request A Copy of the Complaint" (Doc. #7) is denied.

(5) The Complaint (Doc. #1) is dismissed for failure to state a claim. Plaintiff has

30 days from the date this Order is filed to file a first amended complaint in compliance with

this Order.

(6) If Plaintiff fails to file an amended complaint within 30 days, the Clerk of

Court must, without further notice, enter a judgment of dismissal of this action with prejudice

that states that the dismissal counts as a “strike” under 28 U.S.C. § 1915(g).

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

civil rights complaint by a prisoner.

DATED this 18th day of June, 2007.

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Revised 3/9/07 1

Instructions for a Prisoner Filing a Civil Rights Complaint 

in the United States District Court for the District of Arizona

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

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

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

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

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

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

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

entered the judgment. 

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

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

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

questions must be answered clearly and concisely in the appropriate space on the form. If

needed, you may attach additional pages, but no more than fifteen additional pages, of standard

letter-sized paper. You must identify which part of the complaint is being continued and

number all pages. If you do not fill out the form properly, you will be asked to submit additional

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

cite law. 

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

a material fact, you may be prosecuted for perjury.

4. The Filing Fee. The filing fee for this action is $350.00. If you are unable to immediately

pay the filing fee, you may request leave to proceed in forma pauperis. Please review the

“Information for Prisoners Seeking Leave to Proceed with a (Non-Habeas) Civil Action in

Federal Court In Forma Pauperis Pursuant to 28 U.S.C. § 1915” for additional instructions.

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

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

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

identical to the original. Copies may be legibly handwritten.

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

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

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

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

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

in the Tucson Division. Mail the original and one copy of the complaint with the $350 filing

fee or the application to proceed in forma pauperis to:

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Phoenix & Prescott Divisions: OR Tucson Division:

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

U.S. Courthouse, Suite 130 U.S. Courthouse, Suite 1500

401 West Washington Street, SPC 10 405 West Congress Street

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

7. Change of Address. You must immediately notify the Court and the defendants in writing

of any change in your mailing address. Failure to notify the Court of any change in your

mailing address may result in the dismissal of your case.

8. Certificate of Service. You must furnish the defendants with a copy of any document you

submit to the Court (except the initial complaint and application to proceed in forma pauperis).

Each original document (except the initial complaint and application to proceed in forma

pauperis) must include a certificate of service on the last page of the document stating the date

a copy of the document was mailed to the defendants and the address to which it was mailed.

See Fed. R. Civ. P. 5(a), (d). Any document received by the Court that does not include a

certificate of service may be stricken. A certificate of service should be in the following form:

I hereby certify that a copy of the foregoing document was mailed

this (month, day, year) to:

Name: 

Address: 

 Attorney for Defendant(s)

 

(Signature)

9. Amended Complaint. If you need to change any of the information in the initial complaint,

you must file an amended complaint. The amended complaint must be written on the courtapproved civil rights complaint form. You may file one amended complaint without leave

(permission) of Court before any defendant has answered your original complaint. See Fed. R.

Civ. P. 15(a). After any defendant has filed an answer, you must file a motion for leave to

amend and lodge (submit) a proposed amended complaint. LRCiv 15.1. In addition, an

amended complaint may not incorporate by reference any part of your prior complaint. LRCiv

15.1(a)(2). Any allegations or defendants not included in the amended complaint are

considered dismissed. All amended complaints are subject to screening under the Prison

Litigation Reform Act; screening your amendment will take additional processing time.

10. Exhibits. You should not submit exhibits with the complaint or amended complaint.

Instead, the relevant information should be paraphrased. You should keep the exhibits to use

to support or oppose a motion to dismiss, a motion for summary judgment, or at trial.

11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff

of any judge. The only appropriate way to communicate with the Court is by filing a written

pleading or motion.

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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.

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Revised 3/9/07 1 550/555

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

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

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

)

 , )

(Full Name of Plaintiff) Plaintiff, )

)

 vs. ) CASE NO. 

) (To be supplied by the Clerk)

(1) , )

(Full Name of Defendant) )

(2) , )

) CIVIL RIGHTS COMPLAINT

(3) ,) BY A PRISONER

)

(4) , ) G Original Complaint

Defendant(s). ) G First Amended Complaint

G Check if there are additional Defendants and attach page 1-A listing them. ) G Second Amended Complaint

A. JURISDICTION

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

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

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

G Other: .

2. Institution/city where violation occurred: .

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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:

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.

Case 2:07-cv-00379-DGC-DKD Document 10 Filed 06/18/07 Page 15 of 16
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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 2:07-cv-00379-DGC-DKD Document 10 Filed 06/18/07 Page 16 of 16