Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-3_05-cv-02625/USCOURTS-azd-3_05-cv-02625-0/pdf.json

Parties Involved:
Sue Beale
Defendant
John Anthony Pierog
Plaintiff

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 “Doc.#” refers to the docket number of documents filed in this action. 

JDDL-K

WO SC

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

John Anthony Pierog, 

Plaintiff, 

vs.

Sue Beale, 

Defendant. 

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No. CV 05-2625-PCT-MHM (JRI)

ORDER

Plaintiff John Anthony Pierog, an inmate confined in the Arizona State Prison

Complex-Phoenix West, in Phoenix, Arizona, filed this civil rights action pursuant to 42

U.S.C. § 1983. The Court will grant Plaintiff’s application to proceed in forma pauperis and

dismiss the complaint with leave to amend. (Doc.# 1.)1

I. Application to Proceed In Forma Pauperis & Filing Fee

Plaintiff’s request to proceed in forma pauperis will be granted. 28 U.S.C. § 1915(a).

Plaintiff must pay the statutory filing fee of $250.00, beginning with payment of an initial

partial filing fee of $65.63. 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 the fees according to the statutory formula. 

II. Statutory Screening of Prisoner Complaints

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

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2

 He alleges that the failure to secure his property after the search exposed it to

damage from the elements, infestation by rodents, and/or additional damage or theft by third

parties. 

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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 Plaintiff has raised

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

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

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

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

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

Cir. 2000) (en banc). 

The Court is required to grant leave to amend “if a complaint can possibly be saved”

by the allegation of additional facts, but not if the complaint “lacks merit entirely.” Id. at

1129-30. The Court should not, however, advise the litigant how to cure the defects. This

type of advice “would undermine the district judges’ role as impartial decisionmakers.”

Pliler v. Ford, 542 U.S. 225, 231 (2004); see also Lopez, 203 F.3d at 1131 n.13 (declining

to decide whether court was required to inform litigant of deficiencies). Plaintiff’s complaint

will be dismissed for failure to state a claim with leave to amend because he may be able to

state non-frivolous claims for relief by alleging additional facts. 

III. Complaint

Plaintiff filed this action naming only Mohave County Sheriff’s Office (“MCSO”)

Sergeant Sue Beale as a Defendant. He alleges that his personal property, located at Willow

Ranch in Kingman, Arizona, was seized and/or damaged during a consent search performed

by MCSO and that his property was further damaged or stolen as a result of MCSO’s failure

to properly secure his property after the search.2

 Plaintiff alleges violations of his Fourth,

Ninth and Fourteenth Amendment rights. 

IV. Failure to State a Claim

To sustain an action under section 1983, a plaintiff must show (1) that the conduct

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3

 Plaintiff alleges that he revoked his consent and sent three letters to Beale to

ascertain whether stolen items were found and what items had been removed, and requesting

that MCSO secure and repair damage to his property, but received no response. It appears

that he did not attempt to revoke his consent until some weeks after the search. (Id. at 6A.)

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about which he complains was committed by a person acting under the color of state law and

(2) that the conduct deprived the plaintiff of a federal constitutional or statutory right. Wood

v. Ostrander, 879 F.2d 583, 587 (9th Cir. 1989). For a person to be liable in his official

capacity, a plaintiff must allege that the official acted as a result of a policy, practice, or

custom. See Cortez v. County of Los Angeles, 294 F.3d 1186, 1188 (9th Cir. 2001). A

supervisor, in her individual capacity, “is only liable for constitutional violations of [her]

subordinates if the supervisor participated in or directed the violations, or knew of the

violations and failed to act to prevent them.” Taylor v. List, 880 F.2d 1040, 1045 (9th Cir.

1989). Further, “[a] plaintiff must allege facts, not simply conclusions, that show that an

individual was personally involved in the deprivation of his civil rights.” Barren v.

Harrington, 152 F.3d 1193, 1194 (9th Cir. 1998). 

A. Sergeant Beale

The only facts alleged by Plaintiff against Sergeant Beale is that she asked him to sign

a consent to search his property on May 17, 2004, while he was incarcerated in the Phoenix

West prison. (Doc.# 1 at 4.) Plaintiff admits that he signed the consent and alleges that a

copy of the signed consent was faxed to MCSO, which apparently thereafter conducted the

search. (Id.) Plaintiff has not alleged that the Defendant enacted or enforced a policy,

custom, or practice that resulted in the denial of Plaintiff’s civil rights. At most, he only

alleges the Defendant asked him for consent to search, which he gave, and then failed to

respond to subsequent inquiries made by him.3

 (Id. at 4, 6, 6A.) Plaintiff has not alleged the

Defendant either directly violated his constitutional rights or that she was aware of any

violation of his rights, but failed to act. He does not even allege that Beale was present

during the search. In short, Plaintiff fails to state a claim against Sergeant Beale.

///

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B. Fourth Amendment

The Fourth Amendment protects the “right of people to be secure in their persons,

houses, papers, and effects, against unreasonable searches and seizures” absent a warrant

supported by probable cause. U.S. Const. amend. IV. Plaintiff alleges that he consented to

a search of his property but that he did not consent to any seizure from his property. The

Supreme Court has recognized several exceptions to the warrant requirement for seizures

pursuant to a consent search. See e.g., United States v. Jenkins, 876 F.2d 1085, 1088 (2d Cir.

1989); United States v. Soussi, 29 F.3d 565, 571-72 (10th Cir. 1994). Absent a cognizable

exception, whether a seizure pursuant to a consent search violates an individual’s Fourth

Amendment rights turns on the scope of the consent granted. See United States v.

Rodriguez-Preciado, 399 F.3d 1118, 1131 (9th Cir. 2005); United States v. Perez, 37 F.3d

510, 515 (9th Cir. 1994); Jenkins, 876 F.2d at 1088; see also United States v. Gilbreath, 161

Fed. Appx. 700 (9th Cir. 2006). Plaintiff does not allege facts regarding the scope of the

consent to search signed by him or how the search of his property exceeded that scope. If

Plaintiff re-alleges a Fourth Amendment violation in a first amended complaint, it may be

subject to dismissal absent additional allegations of fact regarding the scope of the consent

signed by Plaintiff. 

A civil rights claim brought pursuant to § 1983 that, if successful, would necessarily

undermine the validity of a conviction may not be brought before the prisoner has obtained

a “favorable termination” of the underlying conviction because a prisoner’s sole federal

remedy to challenge the validity of his confinement is a petition for a writ of habeas corpus.

Preiser v. Rodriguez, 411 U.S. 475, 500 (1973). Thus:

[T]o recover damages for allegedly unconstitutional conviction or

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

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

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

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

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

habeas corpus.

Heck v. Humphrey, 512 U.S. 477, 486-87 (1994). That is, a judgment in favor of the

plaintiff in a § 1983 action that would necessarily imply the invalidity of his conviction or

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sentence does not accrue unless and until he has otherwise obtained a favorable termination

of his conviction or sentence, and must be dismissed. Id. at 487, 489. 

Plaintiff is currently incarcerated and challenges a seizure, incident to a search to

which he consented, while he was incarcerated. It is not clear that the seizure about which

Plaintiff complains is unrelated to pending charges or conviction and, therefore, that any

Fourth Amendment claim has accrued under Heck. 

The Complaint is being dismissed with leave to file a first amended complaint. If

Plaintiff chooses to re-allege a Fourth Amendment claim, Plaintiff should allege facts

regarding the scope of the consent signed by him and whether (1) the conduct about which

he complains arise out of events that resulted in a conviction or pending charges, or (2) the

actions arose out of charges that have been either dismissed or for which Plaintiff has been

acquitted.

 D. Fifth and Fourteenth Amendment Due Process 

Plaintiff also alleges a violation of his Fifth and Fourteenth Amendment due process

rights in Counts II and IV. It is the Fourteenth, rather than the Fifth, Amendment that

applies to state actors. Further, where the state makes a meaningful post-deprivation remedy

available, neither a negligent, nor an intentional, deprivation of an inmate’s property by a

state employee violates the inmate’s Fourteenth Amendment right to due process. Parratt v.

Taylor, 451 U.S. 527, 541 (1981) (negligent); Hudson v. Palmer, 468 U.S. 517, 533 (1984)

(intentional). The availability of a common-law tort suit against a state employee constitutes

an adequate post-deprivation remedy. Hudson, 468 U.S. at 534-35. If Plaintiff chooses to

re-allege violations of his Fifth and/or Fourteenth Amendment due process rights in a first

amended complaint, such claims may be subject to dismissal for failure to state a claim.

D. Count III - Ninth Amendment

Plaintiff alleges that his Ninth Amendment rights were violated by the seizure of,

and/or damage to, his personal property. The Ninth Amendment provides that “the

enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage

others retained by the people.” U.S. Const. amend. IX. The Ninth Amendment “has never

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been recognized as independently securing any constitutional right[] for purposes of pursuing

a civil rights claim.” Strandberg v. City of Helena, 791 F.2d 744, 748-49 (9th Cir. 1986); see

also San Diego County Gun Rights Comm. v. Reno, 98 F.3d 1121, 1125 (9th Cir. 1996)

(collecting authorities rejecting the Ninth Amendment as independently securing

constitutional rights). Instead, a civil rights claim must be based on a specific constitutional

guarantee. Strandberg, 791 F.2d at 749 (collecting United States Supreme Court authorities).

If Plaintiff chooses to re-allege a Ninth Amendment violation in a first amended complaint,

such claim will be dismissed for failure to state a claim. 

IV. Leave to Amend

For the foregoing reason, Plaintiff’s Complaint will be dismissed with leave to amend.

Within 30 days, Plaintiff must submit a First Amended Complaint to cure the deficiencies.

The Clerk of Court will mail Plaintiff a court-approved form to use for his First Amended

Complaint. 

Plaintiff must clearly designate on the face of the document that it is a 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 will supersede 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 Complaint will be treated as

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

Complaint but not in the first amended complaint is waived. King v. Atiyeh, 814 F.2d 565,

567 (9th Cir. 1987).

V. Warnings

A. Release

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

Also, within 30 days of his release, he must either (1) notify the Court that he intends to pay

the balance, or (2) show good cause, in writing, why he cannot. Failure to comply may result

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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 he 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 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 (district court may dismiss action for failure to comply with any

order of the Court).

IT IS ORDERED: 

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

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

Plaintiff must pay the $250.00 filing fee, and is assessed an initial partial filing fee of $65.63.

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

have 30 days from the date this Order is filed to file a First Amended Complaint in

compliance with this Order.

(4) If Plaintiff fails to comply, the Clerk of Court will enter a judgment of dismissal

with prejudice and without further notice and will indicate that the dismissal is pursuant to

28 U.S.C. § 1915(g).

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

rights complaint by a prisoner.

DATED this 6th day of July, 2006.

Case 3:05-cv-02625-MHM Document 3 Filed 07/10/06 Page 8 of 20
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: 

.

Case 3:05-cv-02625-MHM Document 3 Filed 07/10/06 Page 15 of 20
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b. Court: (If federal court, identify the district; if state court, identify the county.) 

.

c. Case or docket number: .

d. Claims raised: 

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

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

4. Second prior lawsuit:

a. Parties to previous lawsuit:

Plaintiff: .

Defendants: 

.

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

.

c. Case or docket number: .

d. Claims raised: 

.

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

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

5. Third prior lawsuit:

a. Parties to previous lawsuit:

Plaintiff: .

Defendants: 

.

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

.

c. Case or docket number: .

d. Claims raised: 

.

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

.

f. Approximate date lawsuit was filed: .

g. Approximate date of disposition: .

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

Case 3:05-cv-02625-MHM Document 3 Filed 07/10/06 Page 16 of 20
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C. CAUSE OF ACTION

COUNT I

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

.

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

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

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

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

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

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

authority or arguments).

.

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

.

5. Administrative Remedies:

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

your institution? G Yes G No

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

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

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

why you did not. 

.

Case 3:05-cv-02625-MHM Document 3 Filed 07/10/06 Page 17 of 20
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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. 

.

Case 3:05-cv-02625-MHM Document 3 Filed 07/10/06 Page 18 of 20
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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.)

Case 3:05-cv-02625-MHM Document 3 Filed 07/10/06 Page 19 of 20
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D. REQUEST FOR RELIEF

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

.

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

Executed on 

DATE SIGNATURE OF PLAINTIFF

(Name and title of paralegal, legal assistant, or

other person who helped prepare this complaint)

(Signature of attorney, if any)

(Attorney’s address & telephone number)

ADDITIONAL PAGES

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

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

Case 3:05-cv-02625-MHM Document 3 Filed 07/10/06 Page 20 of 20