Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_05-cv-00490/USCOURTS-azd-2_05-cv-00490-0/pdf.json

Parties Involved:
Laron Fitch
Plaintiff
Maricopa County Sheriff's Office
Defendant

Document Text:

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Many inmates apparently believe that they will receive an immediate payout from a fund

established in Hart v. Hill, No. CV 77-0479-PHX-EHC (MS) (D. Ariz.). No such fund exists. The

inmates in Hart asked for injunctive relief and not monetary damages. The Court at this time

expresses no opinion on whether Plaintiff’s lawsuit may result in an award of damages.

JDDL - 1 -

WO RP

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Laron Fitch,

Plaintiff, 

vs.

Maricopa County Sheriff's Office, 

Defendant. 

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No. CV-05-490-PHX-SMM (LOA)

ORDER

Laron Fitch ("Plaintiff"), presently confined in the Maricopa County Durango Jail in

Phoenix, Arizona ("Madison Jail"), filed with the Clerk of the Court on February 10, 2005

a pro se "Civil Rights Complaint By A Prisoner" (Document #1) (the "Complaint") pursuant

to 42 U.S.C. § 1983. This action is one of more than one thousand (1,000) lawsuits filed in

this district since September 2004 alleging that the overcrowded conditions in the Maricopa

County jail system have resulted in a variety of constitutional violations.1

Plaintiff has not paid a filing fee, but he has filed a certified "Application To Proceed In

Forma Pauperis By A Prisoner Civil" (Non-Habeas) (the "Application To Proceed") and an

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"Inmate Account Statement" (the "Account Statement") with his Complaint. 

APPLICATION TO PROCEED IN FORMA PAUPERIS AND FILING FEE

Plaintiff’s certified Application To Proceed and Account Statement filed with the

Complaint make the showing required by 28 U.S.C. § 1915(a). Accordingly, Plaintiff’s

Application to Proceed will be granted. 

Pursuant to 28 U.S.C. § 1915(b)(1), as amended by the Prison Litigation Reform Act of

1995, Pub. L. No. 104-134, 110 Stat. 1321 (Apr. 26, 1996), “if a prisoner brings a civil action

or files an appeal [in forma pauperis], the prisoner shall be required to pay the full amount

of a filing fee.” 28 U.S.C. § 1915(b)(1). Effective February 7, 2005, the filing fee for a civil

rights action increased from one hundred and fifty dollars ($150.00) to two hundred and fifty

dollars ($250.00). See 28 U.S.C. § 1914, amended by, Consolidated Appropriations Act of

2005, Pub. L. No. 108-447, 118 Stat. 2809, Sec. 307 (December 8, 2004). Plaintiff’s

Complaint, however, is not subject to the increased fee. 

Under the “prison mailbox rule,” a complaint is deemed “filed” when handed by the

prisoner to a prison official for mailing. See Houston v. Lack, 487 U.S. 266, 270-71 (1988);

Stillman v. LaMarque, 319 F.3d 1199, 1201 (9th Cir. 2003). Although his Complaint was

received by the Court after the effective date of the fee increase, the Complaint appears to

have been “filed” prior to the effective date under the “prison mailbox rule.” Accordingly,

Plaintiff is obligated to pay only the one hundred and fifty dollar ($150.00) filing fee.

Based on the average monthly deposits in Plaintiff’s account for four (4) months preceding

the filing of the Complaint, an initial partial filing fee of seventeen dollars and fifty-five cents

($17.55) will be assessed by this Order. 28 U.S.C. § 1915(b)(1).

By separate order, the Court will direct the appropriate agency to collect the initial partial

filing fee from Plaintiff’s trust account and forward it to the Clerk of the Court. Thereafter,

Plaintiff will be obligated for monthly payments of twenty percent (20%) of the preceding

month’s income credited to Plaintiff’s trust account. These payments will be forwarded by

the appropriate agency to the Clerk of the Court each time the amount in Plaintiff’s account

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exceeds ten dollars ($10.00), until the filing fee is paid in full. 28 U.S.C. § 1915(b)(2).

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

pay the remaining unpaid amount of the filing fee within one hundred and twenty (120) days

of the date of his release. If Plaintiff fails to pay the remainder of the filing fee within one

hundred and twenty (120) days of the date of his release, the action will be dismissed, unless

Plaintiff shows good cause, in writing, why he is unable to pay the remainder of the filing

fee.

Plaintiff also should take notice that a prisoner may not bring a civil action without

complete prepayment of the appropriate filing fee if the prisoner has brought, on three (3) or

more occasions, an action or appeal in a federal court that was dismissed as frivolous, as

malicious, or for failure to state a claim upon which relief may be granted, unless the prisoner

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

STATUTORY SCREENING OF PRISONER COMPLAINTS

The Court is required to screen complaints or amended complaints brought by prisoners

seeking relief against a governmental entity or officer or employee of a governmental entity.

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

portion thereof if Plaintiff fails to exhaust any administrative remedy available to him. 42

U.S.C. § 1997e(a).

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

pro se litigant is entitled to an opportunity to amend the complaint before dismissal of the

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

is required to grant leave to amend "if a complaint can possibly be saved," but not if the

Complaint "lacks merit entirely." Id. at 1129. A court therefore should grant leave to amend

if the pleading could be cured by the allegation of other facts, or if it appears at all possible

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that the defect can be corrected. Id. at 1130.

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

advice "would undermine the district judges' role as impartial decisionmakers." Pliler v.

Ford, 124 S.Ct. 2441, 2446 (2004); see also Lopez, 203 F.3d at 1131, n.13 (declining to

decide whether court was required to inform litigant of deficiencies). Plaintiff's Complaint

will be dismissed with leave to amend because the Complaint may possibly be saved by

amendment.

COMPLAINT

Plaintiff alleges three (3) counts in his Complaint. (Complaint at 4-6). In Count I,

Plaintiff claims that he has been subjected to overcrowding. Id. at 4. In Count II, Plaintiff

claims that he is receiving only two (2) meals a day and the food is frequently rotten and has

contained foreign objects. Id. at 5. In Count III, Plaintiff claims that he is not being afforded

recreation time as required. Id. at 6. 

Named as Defendant in the Complaint is the Maricopa County Sheriff's Office.

(Complaint at 1-2).

Plaintiff seeks monetary damages and medical coverage after his release. (Complaint at

7).

DISMISSAL OF DEFENDANT

The Maricopa County Sheriff’s Office is also not a proper Defendant. In Arizona, the

responsibility of operating jails and caring for prisoners is placed by law upon the sheriff.

See A.R.S. § 11-441(A)(5); A.R.S. § 31-101. A sheriff’s office is simply an administrative

creation of the county sheriff to allow him to carry out his statutory duties, and not a

“person” amenable to suit pursuant to § 1983. Therefore, the Maricopa County Sheriff’s

Office will be dismissed without prejudice from this action pursuant to 28 U.S.C. §§

1915(e)(2)(B)(ii) and 1915A(b)(1) for failure to state a claim upon which relief may be

granted.

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FAILURE TO STATE A CLAIM

Constitutional Violation

The deficiencies in Plaintiff's Complaint go beyond his failure to name a proper

Defendant. In order to entertain a claim under 42 U.S.C. § 1983, Plaintiff must show that the

conduct of the Defendants deprived him of a federal constitutional right. Haygood v.

Younger, 769 F.2d 1350, 1354 (9th Cir. 1985) (en banc), cert. denied, 478 U.S. 1020 (1986).

However, Plaintiff makes no reference whatsoever to a federal constitutional right in Count

I, II, or III of his Complaint. 

More specifically, Plaintiff has failed to the allege that the conditions in the Madison Jail

created the "wanton and unnecessary infliction of pain" as required to state an Eighth or

Fourteenth Amendment conditions of confinement claim. Rhodes v. Chapman, 452 U.S.

337, 347 (1981). The inquiry with respect to pretrial detainees is whether the prison

conditions amount to “punishment” without due process in violation of the Fourteenth

Amendment. Bell v. Wolfish, 441 U.S. 520, 535 (1979). Generally, a prison's "obligation

under the [E]ighth [A]mendment is at an end if it furnishes sentenced prisoners with adequate

food, clothing, shelter, sanitation, medical care, and personal safety." Hoptowit v. Ray, 682

F.2d 1237, 1246 (9th Cir.1982) (quotations omitted). However, this does not mean that

federal courts can or should interfere whenever prisoners are inconvenienced or suffer de

minimis injuries. See Bell, 441 U.S. at 539 n.21 (noting that a de minimis level of imposition

does not rise to a constitutional violation). Accordingly, Counts I, II, and III of the

Complaint will be dismissed without prejudice pursuant to 28 U.S.C. §§ 1915(e)(2)(B)(ii)

and 1915A(b)(1) for failure to state a claim upon which relief may be granted. 

DISMISSAL OF COMPLAINT WITH 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 (3d Cir. 1979). Further, a liberal interpretation of a civil rights complaint may

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

Because no Defendants now remain, and Plaintiff has failed to allege a constitutional

violation, the Complaint will be dismissed without prejudice. However, in keeping with "the

rule favoring liberality in amendments to pleadings," the Court will exercise its discretion

and allow Plaintiff to file an amended complaint, if he so desires, to show what constitutional

rights he has been deprived of, and how the conduct of proper defendants deprived him of

said rights. Noll v. Carlson, 809 F.2d 1446, 1448 (9th Cir. 1987). 

If Plaintiff chooses to file an amended complaint, he should take notice that an 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 original pleading is treated as nonexistent. Ferdik, 963 F.2d at 1262.

Thus, causes of action alleged in an original complaint which are not alleged in an amended

complaint are waived. King, 814 F.2d at 567. 

 Any amended complaint filed by Plaintiff must be retyped or rewritten in its entirety on

the current, Court-approved form included with this Order and may not incorporate any part

of the original Complaint by reference. See Rule 15.1(a)(2), Local Rule of Civil Procedure

("LRCiv"). If Plaintiff cannot fit all of his supporting facts in favor of a particular count on

the Court-approved form, then he may continue on an attachment, but each matter on any

attachment must be clearly referenced to a particular count on the Court-approved form, and

be numbered appropriately. Plaintiff may only address one (1) issue in each count.

WARNING

Plaintiff is warned that if he fails to timely comply with every provision of this Order, this

action will be dismissed without further notice. See Ferdik, 963 F.2d at 1260-61 (stating that

a district court may dismiss action for failure to comply with any order of the court).

Moreover, because the Complaint has been dismissed for failure to state a claim, if Plaintiff

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

dismissal of this action will count as a “strike” under the “three strikes” provision of the

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Prison Litigation Reform Act. See 28 U.S.C. § 1915(g).

IT IS THEREFORE ORDERED:

(1) That Plaintiff's “Application To Proceed In Forma Pauperis By A Prisoner Civil

(Non-Habeas)” filed with the Complaint is GRANTED;

(2) That Plaintiff is OBLIGATED to pay the statutory filing fee of one hundred and fifty

dollars ($150.00) for this action. Plaintiff is ASSESSED an initial partial filing fee of

seventeen dollars and fifty-five cents ($17.55). All fees shall be collected and paid in

accordance with this Court’s Order to the Maricopa County Sheriff filed concurrently

herewith;

 (3) That Plaintiff's "Civil Rights Complaint By A Prisoner" (Document #1) is

DISMISSED WITHOUT PREJUDICE, WITH LEAVE TO AMEND, pursuant to 28 U.S.C.

§§ 1915(e)(2)(B)(ii) and 1915A(b)(1) for failure to state a claim upon which relief may be

granted. Plaintiff SHALL HAVE thirty (30) days from the filing date of this Order to file

an amended complaint in order to state specific allegations of deprivation of constitutional

rights against proper defendant(s), to name as defendant(s) the individual(s) who participated

in the activities alleged in his amended complaint, to state what injury he has suffered as a

result of the activities of the defendant(s), and to show how, prior to filing this action, he

exhausted his administrative remedies as to each of his claims for relief. The amended

complaint must be retyped or rewritten in its entirety on the current, Court-approved form

included with this Order, may not incorporate any part of the original Complaint by

reference, and must contain Plaintiff’s original signature. If Plaintiff fails to file the

amended complaint on a current, Court-approved form, the amended complaint will be

stricken, and the action dismissed without further notice to Plaintiff. Any amended

complaint submitted by Plaintiff should be clearly designated as an amended complaint on

the face of the document;

(4) That the Clerk of the Court is DIRECTED to enter a judgment of dismissal with

prejudice of this action, without further notice to Plaintiff, if Plaintiff fails to file an amended

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complaint within thirty (30) days from the filing date of this Order. Upon entry of judgment,

the Clerk of the Court SHALL MAKE an entry on the docket in this matter indicating that

the dismissal of this action falls within the purview of 28 U.S.C. § 1915(g);

(5) That a clear, legible copy of every pleading or other document filed SHALL

ACCOMPANY each original pleading or other document filed with the Clerk for use by the

District Judge or Magistrate Judge to whom the case is assigned. See LRCiv 5.4. 

Failure to submit a copy along with the original pleading or document will result in the

pleading or document being stricken without further notice to Plaintiff;

(6) That at all times during the pendency of the instant action, Plaintiff SHALL

IMMEDIATELY ADVISE the Court and the United States Marshal of any change of address

and its effective date. Such notice shall be captioned “NOTICE OF CHANGE OF

ADDRESS.” The notice shall contain only information pertaining to the change of address

and its effective date, except that if Plaintiff has been released from custody, the notice

should so indicate. The notice shall not include any motions for any other relief. Failure to

file a NOTICE OF CHANGE OF ADDRESS may result in the dismissal of the action for

failure to prosecute pursuant to Federal Rule of Civil Procedure 41(b); 

(7) That the Clerk of the Court is DIRECTED to provide Plaintiff with a current, Courtapproved form for filing a civil rights complaint pursuant to 42 U.S.C. § 1983.

DATED this 1st day of December, 2005.

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Revised 2/7/05 1

INFORMATION AND INSTRUCTIONS FOR A

PRISONER FILING CIVIL RIGHTS COMPLAINT

 IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

I. General Information About the Civil Rights Complaint Form:

A. The Form. The civil rights complaint form is designed to help prisoners prepare a

complaint seeking relief for a violation of their federal civil rights. Local Rule of Civil Procedure

3.4(a) requires that prisoner civil rights complaints be filed on the court-approved form. Your

complaint must be typewritten or legibly handwritten. All information must be clearly and

concisely written, only in the space provided on the form. If needed, you may attach no more

than fifteen additional pages of standard letter size paper to continue any part of the complaint.

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

B. Your Signature. You must sign the complaint. Your signature constitutes a certificate that:

1) you have read the complaint; 2) to the best of your knowledge, information and belief formed

after reasonable inquiry it is well grounded in fact and law; and 3) it is not being filed for any

improper purpose. Please review Rule 11 of the Federal Rules of Civil Procedure. Rule 11

provides for the imposition of sanctions if the complaint is signed in violation of the Rule. 

C. The Filing Fee. You must pay the $250.00 filing fee. If you are unable to pay the filing

fee when the complaint is filed, you may request leave to proceed in forma pauperis. Please

review the "Information for Prisoners Seeking Leave to Proceed with a (Non-Habeas) Civil

Action in Federal Court In Forma Pauperis Pursuant to 28 U.S.C. § 1915" for more

information.

D. Court Divisions. If you resided in Maricopa, Pinal, Yuma, La Paz, or Gila county when

your rights were allegedly violated, you should file your complaint in the Phoenix Division of

the court. If you resided in Apache, Navajo, Coconino, Mohave, or Yavapai county when your

rights were allegedly violated, you should file your complaint in the Prescott Division of the

court. If you resided in Pima, Cochise, Santa Cruz, Graham, or Greenlee county when your

rights were allegedly violated, you should file your complaint in the Tucson Division of the court.

See LRCiv 5.1(a) and 77.1(a). 

You should mail THE ORIGINAL AND ONE COPY of your complaint with the

$250.00 filing fee or the application to proceed in forma pauperis to:

Phoenix & Prescott Divisions: OR Tucson Division:

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

U.S. Courthouse, Suite 321 U.S. Courthouse, Suite 1500

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401 West Washington Street, SPC 10 405 West Congress Street

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

E. Certificate of Service on Defendants. You must furnish the opposing party or their attorney

with a copy of any document you submit to the court (except the initial complaint and

application to proceed in forma pauperis). Pursuant to Rules 5(a) and (d) of the Federal Rules

of Civil Procedure, each original document (except the initial complaint and application for leave

to proceed in forma pauperis) must include a certificate of service on the last page of the

document stating the date a copy of the document was mailed to the opposing party or their

attorney and the address to which it was mailed. Any document received by the court which

does not include a certificate of service may be stricken. A certificate of service should be in

the following form:

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

this day of (month) , (year) , to:

Name: 

Address: 

 Attorney for Defendant(s)/Respondent(s)

 

(Signature)

F. Original and Judge's Copy. You must furnish an original and one copy of any document

submitted to the court. You must furnish one additional copy to the clerk if you wish to have

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

original.

G. Exhibits. You should not submit exhibits with the complaint. Instead, the relevant

information should be paraphrased in the complaint. You should keep the exhibits to use to

support or oppose a motion for summary judgment or at trial.

H. Change of Address. You must immediately notify the clerk and the opposing party or their

attorney in writing of any change in your mailing address. Failure to notify the court of any

change in your mailing address may result in the dismissal of your case.

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

you must file an amended complaint. The amended complaint must be written on the courtapproved civil rights complaint form. Rule 15(a) of the Federal Rules of Civil Procedure allows

you to file one amended complaint prior to any defendant filing an answer. After any defendant

has filed an answer, you must file a motion for leave to amend and lodge a proposed amended

complaint. Local Rule of Civil Procedure 15.1(a)(2) prohibits any amended pleading from

referencing any prior pleading. Further, any allegations or defendants not included in the

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amended complaint are considered dismissed.

J. Letters and Motions. It is generally inappropriate to write a letter to any of the District

Judges, Magistrates Judges, or the staff of any of the judicial officers. The appropriate way to

communicate with these persons is by filing a written pleading or motion. 

II. Completing the Civil Rights Complaint Form:

HEADING:

1. Your Name. Print your name, prison or jail inmate number, and mailing address on

the lines provided. 

2. Defendants. Print the names of each of your defendants. If you name more than

four defendants, you should print the name of one defendant and "see additional page

for defendants" in the space provided. On the additional page you must list the names

of all of the defendants. This additional page should be inserted after page 1 and

numbered as page "1-A" at the bottom of the page. The initial complaint must contain

the names of all of the parties (plaintiffs as well as defendants) in the heading (or on the

additional page if more than four defendants). See Rule 10(a) of the Federal Rules of

Civil Procedure.

3. Jury Demand. If you want a jury trial, you must write "JURY TRIAL DEMANDED"

on the line below "CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do so

will result in the loss of the right to a jury trial. A jury trial is not available if you are

seeking only injunctive relief.

Part A. JURISDICTION:

1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. §

1983 for state, county, or city defendants; "Bivens v. Six Unknown Federal Narcotics

Agents" for federal defendants; or "other." If you mark "other," identify the source of

that authority. 

2. Plaintiff. Print all of the requested information on the spaces provided. Identify the

institution and city where the alleged violation of your rights occurred. 

3. Defendants. Print all of the requested information about each of the defendants in

the spaces provided. If you are naming more than four defendants, you must provide the

necessary information about each additional defendant on a separate page. Label the

page(s) as "2-A," "2-B," etc., at the bottom of the page and insert the additional

page(s) immediately behind page 2.

Part B. PREVIOUS LAWSUITS:

You must identify any other lawsuit you have filed in either state or federal court while

you were a prisoner. Print all of the requested information about each lawsuit in the spaces

provided. If you have filed more than three lawsuits, you must provide the necessary

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information about each additional lawsuit on a separate page. Label the page(s) as "2-A," "2-

B," etc., at the bottom of the page and insert the additional page(s) immediately behind page

2.

Part C. CAUSE OF ACTION:

You must identify what rights the defendant(s) violated. The form provides space to

allege three separate counts (one violation per count). If you are alleging more than three

counts, you must provide the necessary information about each additional count on a separate

page. Number the additional pages "5-A", "5-B", etc., and insert them immediately behind

page 5. Remember that you are limited to a total of fifteen additional pages.

 

1. Counts. You must identify which civil right was violated. YOU MAY ALLEGE THE

VIOLATION OF ONLY ONE CIVIL RIGHTS CLAIM PER COUNT.

2. Issue Involved. Check the box that most closely identifies the issue involved in your

claim. YOU MAY CHECK ONLY ONE BOX PER COUNT. If you check the box

marked “Other,” you must identify the specific issue involved in the space provided.

3. Supporting Facts. After you have identified which civil right was violated, you need

to state the supporting facts. Be as specific as possible. You must state what each

individual defendant did to violate your rights. If there is more than one defendant, you

need to identify which defendant did what act. You also need to state the date(s) on

which the act(s) occurred if possible.

4. Injury. State precisely how you were injured by the alleged violation of your rights.

5. Administrative Remedies. Exhaustion of administrative remedies is a prerequisite

to filing a civil rights complaint. 42 U.S.C. § 1997e requires prisoners to exhaust the

available administrative remedies before being allowed to file a civil rights action.

Consequently, you must disclose whether you have exhausted the inmate grievance

procedures or administrative appeals for each count in your complaint. If one of your

counts is exempt from the grievance procedures or administrative appeals, fully explain

the exemption on the lines provided.

Part D. REQUEST FOR RELIEF:

Print the relief you are seeking in the space provided. 

SIGNATURE:

You must sign your name and print the date you signed the complaint. Your signature

must be an original signature, not a photocopy. 

FINAL NOTE

You should follow these instructions carefully. Failure to do so may result in your

complaint being stricken or dismissed by the court. All questions must be answered concisely

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in the proper space on the form. If needed, you may attach no more than fifteen additional

pages. The form, however, must be completely filled in to the extent applicable. If you attach

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

number the pages.

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Revised 2/7/05 1 550/555

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

)

 , )

(Full Name of Plaintiff) Plaintiff, )

)

 vs. ) CASE NO. 

) (To be supplied by the Clerk)

 , )

)

 , )

) CIVIL RIGHTS COMPLAINT

 ,) BY A PRISONER

)

 , ) G Original Complaint

(Full Name of Each Defendant) Defendant(s). ) G First Amended Complaint

) G Second Amended Complaint

A. JURISDICTION

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

a. G 28 U.S.C. § 1343(a)(3); 42 U.S.C. § 1983

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

c. G Other: (Please specify.) .

2. Name of Plaintiff: .

Present mailing address: .

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

Institution/city where violation occurred: .

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3. Name of first Defendant: . The first Defendant is employed as:

at . (Position and Title) (Institution)

The first Defendant is sued in his/her: G individual capacity G official capacity (check one or both).

Explain how the first Defendant was acting under color of law: 

.

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

at . (Position and Title) (Institution)

The second Defendant is sued in his/her: G individual capacity G official capacity (check one or both).

Explain how the second Defendant was acting under color of law: 

.

5. Name of third Defendant: . The third Defendant is employed as:

at . (Position and Title) (Institution)

The third Defendant is sued in his/her: G individual capacity G official capacity (check one or both).

Explain how the third Defendant was acting under color of law: 

.

6. Name of fourth Defendant: . The fourth Defendant is employed as:

at . (Position and Title) (Institution)

The fourth Defendant is sued in his/her: G individual capacity G official capacity (check one or both).

Explain how the fourth Defendant was acting under color of law: 

.

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

B. PREVIOUS LAWSUITS

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

2. If your answer is "yes," how many lawsuits have you filed? . Describe the previous lawsuits in the

spaces provided below.

3. First prior lawsuit:

a. Parties to previous lawsuit:

Plaintiff: .

Defendants: 

.

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b. Court: (If federal court, identify the district; if state court, identify the county.) 

.

c. Case or docket number: .

d. Claims raised: 

e. Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?) 

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

4. Second prior lawsuit:

a. Parties to previous lawsuit:

Plaintiff: .

Defendants: 

.

b. Court: (If federal court, identify the district; if state court, identify the county.) 

.

c. Case or docket number: .

d. Claims raised: 

.

e. Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?) 

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

5. Third prior lawsuit:

a. Parties to previous lawsuit:

Plaintiff: .

Defendants: 

.

b. Court: (If federal court, identify the district; if state court, identify the county.) 

.

c. Case or docket number: .

d. Claims raised: 

.

e. Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?) 

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

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

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C. CAUSE OF ACTION

COUNT I

1. The following constitutional or other federal civil right has been violated by the Defendant(s): 

.

2. Count I involves: (Check only one; if your claim involves more than one issue, each issue should be stated

in a different count) G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

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

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

Defendant did or did not do to violate your rights. State the facts clearly in your own words without citing legal

authority or arguments).

.

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

.

5. Administrative Remedies:

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

your institution? G Yes G No

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

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

d. If you did not submit or appeal a request for administrative relief to the highest level, briefly explain

why you did not. 

.

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COUNT II

1. The following constitutional or other federal civil right has been violated by the Defendant(s): 

.

2. Count II involves: (Check only one; if your claim involves more than one issue, each issue should be stated

in a different count) G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

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

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

each Defendant did or did not do to violate your rights. State the facts clearly in your own words without citing

legal authority or arguments).

.

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

.

5. Administrative Remedies:

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

your institution? G Yes G No

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

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

d. If you did not submit or appeal a request for administrative relief to the highest level, briefly explain

why you did not. 

.

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COUNT III

1. The following constitutional or other federal civil right has been violated by the Defendant(s): 

.

2. Count III involves: (Check only one; if your claim involves more than one issue, each issue should be stated

in a different count) G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

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

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

each Defendant did or did not do to violate your rights. State the facts clearly in your own words without citing

legal authority or arguments).

.

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

.

5. Administrative Remedies:

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

your institution? G Yes G No

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

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

d. If you did not submit or appeal a request for administrative relief to the highest level, briefly explain

why you did not. 

.

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

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D. REQUEST FOR RELIEF

State briefly exactly what you want the Court to do for you.

.

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

Executed on 

DATE SIGNATURE OF PLAINTIFF

(Name and title of paralegal, legal assistant, or

other person who helped prepare this complaint)

(Signature of attorney, if any)

(Attorney’s address & telephone number)

ADDITIONAL PAGES

All questions must be answered concisely in the proper space on the form. If needed, you may attach no more

than fifteen additional pages. The form, however, must be completely filled in to the extent applicable.

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