Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_24-cv-03676/USCOURTS-azd-2_24-cv-03676-0/pdf.json

Parties Involved:
NaphCare Incorporated
Defendant
Calvin Clinton Ward
Plaintiff

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JL

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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Calvin Clinton Ward,

Plaintiff, 

v. 

NaphCare Incorporated,

Defendant.

No. CV-24-03676-PHX-JAT (JZB)

ORDER

Plaintiff Calvin Clinton Ward, who is confined in the Arizona State Prison 

Complex-Eyman, has filed a pro se civil rights Complaint pursuant to 42 U.S.C. 

§ 1983 (Doc. 1) and an Application to Proceed In Forma Pauperis (Doc. 2). The Court will 

dismiss the Complaint with leave to amend.

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 $26.78. The remainder 

of 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. Statutory Screening of Prisoner Complaints

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

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against a governmental entity or an officer or an employee of a governmental entity. 28 

U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff 

has raised claims that are legally frivolous or malicious, that fail to state a claim upon which 

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

such relief. 28 U.S.C. § 1915A(b)(1)–(2). 

A pleading must contain a “short and plain statement of the claim showing that the 

pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 does 

not demand detailed factual allegations, “it demands more than an unadorned, thedefendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678 

(2009). “Threadbare recitals of the elements of a cause of action, supported by mere 

conclusory statements, do not suffice.” Id.

“[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a 

claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly, 

550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual content 

that allows the court to draw the reasonable inference that the defendant is liable for the 

misconduct alleged.” Id. “Determining whether a complaint states a plausible claim for 

relief [is] . . . a context-specific task that requires the reviewing court to draw on its judicial 

experience and common sense.” Id. at 679. Thus, although a plaintiff’s specific factual 

allegations may be consistent with a constitutional claim, a court must assess whether there 

are other “more likely explanations” for a defendant’s conduct. Id. at 681.

But as the United States Court of Appeals for the Ninth Circuit has instructed, courts 

must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 342 

(9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less stringent 

standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. Pardus, 551 

U.S. 89, 94 (2007) (per curiam)). 

If the Court determines that a pleading could be cured by the allegation of other 

facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal 

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

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Court will dismiss Plaintiff’s Complaint for failure to state a claim, but because it may 

possibly be amended to state a claim, the Court will dismiss it with leave to amend.

III. Complaint 

In his single-count Complaint, Plaintiff names NaphCare Incorporated 

(“NaphCare”) as the sole Defendant. Plaintiff asserts a claim regarding his medical care. 

He seeks declaratory, injunctive, and compensatory relief, punitive damages, and his fees 

and expenses for this case. 

Plaintiff alleges the following:

On May 17, 2024, Plaintiff submitted a health needs request (HNR) stating he had 

several masses on his stomach that were causing him extreme pain. On June 3, 2024, 

Plaintiff submitted another HNR stating he had been waiting weeks to be seen about the 

painful masses/lumps on his torso, that the “situation had gotten much worse,” and that 

there was something “seriously wrong.” On June 12, 2024, Plaintiff submitted a third HNR 

again stating that he had been waiting weeks to be seen for the painful masses that were all 

over his torso. Plaintiff wrote that his pain was at an 8 out of 10 “all the time.”

On June 20, 2024, Plaintiff submitted an informal complaint against NaphCare. 

Plaintiff stated that he had numerous masses on his torso that were causing him extreme 

pain and that his pain was at an 8 out of 10 all the time. Plaintiff wrote that the pain was 

affecting his “everyday life,” and it was “almost impossible to sleep.” Plaintiff stated that 

the masses were “getting bigger fast” and asked that the informal complaint be treated as 

an emergency request for medical care. Plaintiff did not receive a response to his informal 

complaint.

On July 16, 2024, Plaintiff submitted a grievance against NaphCare, again stating 

that he had masses growing all over his torso that were causing him extreme pain, that the 

masses were getting bigger “really fast,” and that his pain was now at a 10 out of 10 every 

day, even in his sleep. Plaintiff wrote that sleep was impossible, and his medical situation 

was affecting his everyday life. Plaintiff asked that the grievance be treated as an 

emergency request for medical care. On August 6, 2024, Plaintiff received a response to 

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his grievance stating that his informal complaint had been answered on July 12, 2024, that 

Plaintiff was scheduled for an ultrasound and then to see a dermatologist, and that a 

treatment plan would be determined based on the results of the test and the specialist visit. 

On August 7, 2024, Plaintiff submitted a grievance appeal. Plaintiff explained “his 

entire medical situation” and stated that he “was at a complete loss as to what to do because 

he believed that it was ‘now clear’” that NaphCare “just did not care about him.” Plaintiff 

wrote that he was experiencing very intense pain that had “made its way into his hernia,” 

the upper right side of his leg, and into his right testicle, which was purple and bruised. 

Plaintiff’s grievance appeal was denied. The response stated that an ultrasound had been 

performed and that a treatment plan would be determined “by the results of the diagnostic 

tests ordered.” 

On August 24, 2024, Plaintiff submitted an HNR “begging for help. Plaintiff stated 

he was in an “extreme amount of pain,” and that the pain had moved into his hernia, his 

right testicle, and down his right leg. Plaintiff wrote that it hurt “just to breathe” and asked 

that the HNR be treated as an emergency request for medical care. On September 28, 2024, 

Plaintiff submitted an HNR stating that he was still in extreme pain, and the pain 

medication he had been given had “done absolutely nothing to help” his pain. On October 

3, 2024, Plaintiff submitted an HNR stating that his hernia and right testicle “hurt badly” 

and that the medication he had been given had “not done anything” to help with his pain.

On October 27, 2024, Plaintiff submitted an HNR stating that he was in extreme 

pain all the time and that the pain was shooting down into his right testicle and down both 

his legs. Plaintiff “questioned why the ultrasound that had been conducted only showed 

two of the six lesions that had been found” and asked what the treatment plan was “now 

that a CT scan had finally been conducted.” On November 11, 2024, Plaintiff submitted 

an HNR asking to see NaphCare provider Patricia J. Blanck-Miller to discuss the results of 

the CT scan and to “figure out why her requests for surgery and for a visit with a 

dermatologist had been cancelled.” According to Plaintiff, Blanck-Miller referred Plaintiff 

to a radiologist, dermatologist, and urologist, and requested surgery for the removal of 

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Plaintiff’s lesions and “better pain medication,” but all her referrals and requests were

denied. Plaintiff has had blood tests, undergone an ultrasound and a CT scan, and been 

given generic Tylenol for pain, but he has not been seen by any specialists “to figure out 

what is going on with him medically,” and he has not been given any effective pain 

medication. 

IV. Failure to State a Claim

To state a claim under § 1983 against a private entity performing a traditional public 

function, such as providing medical care to prisoners, a plaintiff must allege facts to support 

that his constitutional rights were violated as a result of a policy, decision, or custom 

promulgated or endorsed by the private entity. See Tsao v. Desert Palace, Inc., 698 F.3d 

1128, 1138-39 (9th Cir. 2012); Buckner v. Toro, 116 F.3d 450, 452 (11th Cir. 1997) (per 

curiam). A plaintiff must allege the specific policy or custom and how it violated his 

constitutional rights. A private entity is not liable merely because it employs persons who 

allegedly violated a plaintiff’s constitutional rights. See Tsao, 698 F.3d at 1139; Buckner, 

116 F.3d at 452. 

Plaintiff alleges that NaphCare’s failure to “take steps to ensure that [he] received 

the needed treatment and care, despite its knowledge of [his] serious medical needs, 

constituted deliberate indifference to [his] serious medical needs.” However, Plaintiff has 

not provided any factual detail regarding any of the responses to the HNRs he submitted 

or the treatment he received. Plaintiff states that he underwent blood tests and diagnostic 

imaging, but he does not state when these tests occurred, the results of the tests, any 

diagnoses he received, what, if any, treatment was recommended, what treatment Plaintiff 

received, and, if any recommended treatment was denied, the reasons given for the denial.

Plaintiff also contends Defendant NaphCare “has a custom and/or policy of ignoring 

the recommendations made by its providers.” That allegation is insufficient to state a claim 

against NaphCare. Plaintiff provides virtually no factual detail concerning his providers’ 

recommendations. Although Plaintiff claims Blanck-Miller requested surgery and a visit 

with a dermatologist, Plaintiff provides no facts regarding these requests, such as when 

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Blanck-Miller made the requests, the reasons she gave for the requests, the nature of the 

surgery she requested, when and by whom the requests were denied, the reasons given for 

the denial, and whether any alternative treatment plans were implemented. As presented, 

Plaintiff fails to state a claim against NaphCare, the sole Defendant. The Court will 

therefore dismiss the Complaint with leave to amend.

V. Leave to Amend

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 filing a first amended complaint. 

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).

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.

. . . .

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B. Address Changes

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

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

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

action.

C. Possible “Strike”

Because the 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 may count as a “strike” under the “3-strikes” provision of 28 U.S.C. § 1915(g). 

Under the 3-strikes provision, a prisoner may not bring a civil action or appeal a civil 

judgment in forma pauperis under 28 U.S.C. § 1915 “if the prisoner has, on 3 or more prior 

occasions, while incarcerated or detained in any facility, brought an action or appeal in a 

court of the United States that was dismissed on the grounds that it is frivolous, malicious, 

or fails to state a claim upon which relief may be granted, unless the prisoner is under 

imminent danger of serious physical injury.” 28 U.S.C. § 1915(g). 

D. Possible Dismissal

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

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

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

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 $26.78.

(3) 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.

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(4) 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 may count as a “strike” under 28 U.S.C. § 1915(g) 

and deny any pending unrelated motions as moot.

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

rights complaint by a prisoner.

Dated this 16th day of January, 2025.

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Revised 11/6/24 

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 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 $405.00 ($350.00 filing 

fee plus $55.00 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. Unless you are an inmate housed at an Arizona Department of Corrections facility 

that participates in electronic filing, mail the original and one copy of the complaint with the 

$405 filing and administrative fees or the application to proceed in forma pauperis to:

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Phoenix & Prescott Divisions: OR Tucson Division: 

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

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

401 West Washington Street, SPC 10 405 West Congress Street 

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

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

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

address may result in the dismissal of your case.

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

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

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

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

document was mailed to the defendants and the address to which it was mailed. See Fed. R. Civ. 

P. 5(a), (d). Any document received by the Court that does not include a certificate of service 

may be stricken. This section does not apply to inmates housed at an Arizona Department 

of Corrections facility that participates in electronic filing. 

A certificate of service should be in the following form: 

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

this (month, day, year) to: 

Name: 

Address: 

 Attorney for Defendant(s) 

 

(Signature) 

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

you must file an amended complaint. The amended complaint must be written on the courtapproved 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 2:24-cv-03676-JAT--JZB Document 6 Filed 01/16/25 Page 12 of 18
Revised 12/1/23 1 550/555

___________________________________________ Name and Prisoner/Booking Number 

___________________________________________ Place of Confinement 

___________________________________________ Mailing Address 

___________________________________________ City, State, Zip Code (Failure to notify the Court of your change of address may result in dismissal of this action.)

IN THE UNITED STATES DISTRICT COURT

 FOR THE DISTRICT OF ARIZONA 

_________________________________________ , 

(Full Name of Plaintiff) 

Plaintiff, 

v. 

(1) _______________________________________ , 

(Full Name of Defendant) 

(2) _______________________________________ , 

(3) _______________________________________ , 

(4) _______________________________________ , 

Defendant(s). 

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

CASE NO. __________________________________ 

 (To be supplied by the Clerk) 

CIVIL RIGHTS COMPLAINT 

BY A PRISONER 

G Original Complaint 

G First Amended Complaint 

G Second Amended Complaint

A. JURISDICTION

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

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

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

G Other: . 

2. Institution/city where violation occurred: . 

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B. DEFENDANTS

1. Name of first Defendant: . The first Defendant is employed 

as: ______________________________________________ at_______________________________________. 

(Position and Title) (Institution)

2. Name of second Defendant: . The second Defendant is employed as: 

as: ______________________________________________ at_______________________________________.

 (Position and Title) (Institution)

3. Name of third Defendant: . The third Defendant is employed 

as: ______________________________________________ at_______________________________________.

 (Position and Title) (Institution)

4. Name of fourth Defendant: . The fourth Defendant is employed 

as: ______________________________________________ at_______________________________________.

 (Position and Title) (Institution) 

If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page.

C. PREVIOUS LAWSUITS

1. Have you filed any other lawsuits while you were a prisoner? G Yes G No 

2. If yes, how many lawsuits have you filed? . Describe the previous lawsuits: 

a. First prior lawsuit: 

1. Parties: v. 

2. Court and case number: . 

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) 

. 

b. Second prior lawsuit: 

1. Parties: v. 

2. Court and case number: . 

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) 

. 

c. Third prior lawsuit: 

1. Parties: v. 

2. Court and case number: . 

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) 

. 

If you filed more than three lawsuits, answer the questions listed above for each additional lawsuit on a separate page.

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D. CAUSE OF ACTION

COUNT I

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

. 

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

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

G Disciplinary proceedings G Property G Exercise of religion G Retaliation 

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

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

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

citing legal authority or arguments. 

. 

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

. 

5. Administrative Remedies: 

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

your institution? G Yes G No 

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

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

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

did not. 

. 

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COUNT II

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

. 

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

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

G Disciplinary proceedings G Property G Exercise of religion G Retaliation 

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

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

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

citing legal authority or arguments. 

. 

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

. 

5. Administrative Remedies. 

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

your institution? G Yes G No 

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

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

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

did not. 

. 

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COUNT III

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

. 

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

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

G Disciplinary proceedings G Property G Exercise of religion G Retaliation 

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

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

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

citing legal authority or arguments. 

. 

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

. 

5. Administrative Remedies. 

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

your institution? G Yes G No 

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

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

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

did not. 

. 

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

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E. REQUEST FOR RELIEF

State the relief you are seeking: 

. 

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

Executed on 

DATE SIGNATURE OF PLAINTIFF 

___________________________________________ 

(Name and title of paralegal, legal assistant, or 

other person who helped prepare this complaint) 

___________________________________________ 

(Signature of attorney, if any) 

___________________________________________ 

(Attorney=s address & telephone number) 

ADDITIONAL PAGES

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

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

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

all pages. 

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