CASE NUMBER ----------

IMPORT ANT NOTICE - READ CAREFULLY 

IN ALL MATTERS IN THE COUNTY COURT WHERE THE FULES OF SUMMARY 

PROCEDURES ARE APPLICABLE, IT IS EXPECTED THAT THE DEFENDANT OR 

DEFENDANTS WILL FILE ANSWERS TO THE STATEMENT OF CLAIM. THE INITIAL 

APPEARANCE SHALL BE FOR A PRETRIAL CONFERENCE. AT THE PRETRIAL 

CONFERENCE ALL MATTERS SPECIFIED IN RULE 1.200 OF THE FLORIDA RULES OF 

CIVIL PROCEDURE SHALL BE CONSIDERED. 

THE FILING OF A DEFENSIVE PLEADING OR OTHER PAPERS SHALL NOT 

EXCUSE THE PERSONAL APPEARANCE OF A PARTY OR HIS/HER ATTORNEY ON 

THE INITIAL APPEARANCE DATE. 

IF YOU INTEND TO HA VE AN ATTORNEY DEFEND YOU, PLEASE DELIVER 

THIS NOTICE TO HIM/HER AT ONCE. IF YOU HAVE ANY QUESTIONS, CALL THE 

CIVIL DIVISION OF THE COUNTY CLERK'S OFFICE AT THE ADDRESS SHOWN ON 

THE ATTACHED SUMMONS (NOTICE OF PRETRIAL HEARING). 

ST A TE YOUR DEFENSE AND, IF YOU ARE FILING ONE, COUNTERSUIT HERE. 

ATTACH ADDITIONAL SHEETS, IF NEEDED 

FILED BY ___ o.c. 

MAY 0 1 2020 

ANGELA E. NOBLE 

CLERK U.S. DIST. CT. 

S. D. OF FLA. - MIAMI 

I HEREBY CERTIFY THAT I FILED THIS NOTICE IN THE OFFICE OF THE CLERK OF 

THE COUNTY COURT AND SENT A COPY OF THE SAME TO THE PLAINTIFF OR 

PLAINTIFF'S ATTORNEY AT 

FILE ALL PLEADINGS: 

COUNTY COURT-CIVIL DIVISION 

201 S.E. 6rn STREET, ROOM 120 

FORT LAUDERDALE, FL. 33301-3303 

DEFENDANT OR ATTORNEY 

ADDRESS 

CITY, ST ATE, ZIP CODE, PHONE NO. 

Case 0:20-cv-60882-WPD Document 1 Entered on FLSD Docket 05/01/2020 Page 1 of 8
Your complaint must be legibly handwritten or typewritten. The Plaintiff or 

Plaintiffs must sign and swear to the complaint. If you need additional space to answer a 

question, you may use the reverse side of this form or an additional blank page. 

Your complaint can be brought in this court only if one or more of the named 

Defendants is located within this district. Further, it is necessary for you to file a separate 

complaint for each claim that you have unless they are all related to the same incident or 

issue. 

In order for this complaint to be filed, it must be accompanied by the filing fee of 

$120.00. In addition, the United States Marshal will require you to pay the cost of 

serving the complaint on each of the defendants. 

If you are unable to pay the filing fee and service costs for this action, you may 

petition the court to proceed in Forma Pauparis. Two blank petitions for this purpose are 

included in this packet. One copy should be filed with your complaint; the other copy is 

for your records. After filling in the petition, you must have it notarized by a notary 

public or other official authorized to administer an oath. 

You will note that you are required to give facts. THE COMPLAINT SHOULD 

NOT CONTAIN LEGAL ARGUMENTS OR CITATIONS. 

When these forms are completed, mail the original and two copies to the Clerk of 

the United States District Court for the Southern District of Florida, 301 North Miami 

Avenue, Miami, Florida 33128-7788. 

I. Previous Lawsuits 

A. Have you begun other lawsuits in State or Federal court dealing with the 

same facts involved in this action or otherwise relating to your 

imprisonment? 

YES (/) NO ( ) 

B. If your answer to A is yes, describe each lawsuit in the space below. (If 

there is more than one lawsuit, describe the additional lawsuits on another 

piece of paper, using the same outline. 

1.. Parties to this previous lawsuit: 

Plaintiffs: Ji',iio CrNA ------'---------------------

Case 0:20-cv-60882-WPD Document 1 Entered on FLSD Docket 05/01/2020 Page 2 of 8
IL 

2. Court (if Federal court, name and district; if State court, name the 

county): Gr-ot,.1ii;vf Cou'!f!+_/ 5ovJ-Le1"ti '),s1nct CouA ~( PloriAev 

3. Docket number: P ------------------ 4. Name of judge to whom case was assigned: __ ? _____ _ 

5. Disposition (for example: Was the case dismissed? Was it 

appealed? Is it still 

pending?): p~nJ;"j 

6. Approximate date of fifing lawsuit: 1~yol J. of e, 

7. Approximate date of disposition: __ !!MJ// pe--nh_J 

~oce ~ present 

confinement: {3roLJJti,-A Coirn-h nA""" .:fc,,,' / 

A. Is there a prisoner grievance procedure in this institution? Yes ( :/) No ( ) 

B. Did you present the facts relating to your compfaint in the state pris511er .it 

grievance procedure? Yes ( V) No ( ~ 

C. If your answer is YES: 

I. What 0 st,eps did you 

take? ll'li t/1,lz.,., I <;k~wi,ild. 111w,.,r:: JI J)..& z:H3; /71,,ys•c•/ flb1,1)t.,: I t111~·h I J•:ts 

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2. What · was the 

result? Q /l.e: 1rirn,11 c(,. {/ n t.nt.r Pl1.J)1t,i IJbac: I J41J cl., r:t;J -lie k, 0,1 o,'\ 

3. If your answer is NO, explain why 

not: IP· ¢tltt °"· ~ ,If t:1t • @Id /kμ 

fl. c De-ft,.,) v,.,f' d,.e.pi.:/it (M,;1l -i4 ,F,5o,i I tl"' 11 J ,d,I<(_-/,. '.)/le11, ii ,s beo~2 ,dii,J,e,, u.fi,,.:i.L:J_1J~lr. up tk f:IM 11:,;\i:, 1-1/4,,.. I t.1 I::. -ll...1n /NJ,11iu,,,,, .J., s11 e;e ,.(. f}/ 

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III. Parties 

(In Item A below, place your name in the first blank and place your present 

address in the second blank. Do the same for additional plaintiffs, if any.) 

In Item B below, place the full name of the defendant in the first blank, his 

official position in the second blank, and his place of employment in the third 

blank. Use Item C for the names, positions, and ]Places of employment of any 

additional defendants. 

Case 0:20-cv-60882-WPD Document 1 Entered on FLSD Docket 05/01/2020 Page 3 of 8
B. Defendant S'-l Jorie$ ../1.- I s·s·i.3 

Is employed as 8n:n--.1P-1) Sheri-/{ SM;je-i I 

at Mili,-11;J";.,/1 555 St"''Ave-_ Ff l111tllu-£,JG. 1(L 3S-;,D/ 

C. Additional 

Defendants: ,7)fpi41tt fnJ-JA) 

tm,Ploye.f A> .. ' i!zrovvviaf '5her1-fr_D-/fite, 

IV. Statement of Claim 

State here as briefly as possible the fact~ of your case. Describe how each 

defendant is involved. Include also the names of other persons involved, 

dates, and places. Do not give any legal arguments or cite any cases or 

statutes. If you intend to allege a number of related claims, number and set 

. forth each claim in a separate paragraph. (Use as many spaces as you need. 

K,e: ~e[MAei.f 5''51· 'Jo11e5 Attach extra sheet if necessary.) 

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Case 0:20-cv-60882-WPD Document 1 Entered on FLSD Docket 05/01/2020 Page 4 of 8
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Case 0:20-cv-60882-WPD Document 1 Entered on FLSD Docket 05/01/2020 Page 6 of 8
. . 

V. Relief 

State briefly exactly what you want the court to do for you. Make no legal 

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!lil./te d1u /':;So .-;f .. ./f rv,e1>1ber. ..J/..,d e,1fo 1,111d 't84. CD~1i) I~ is t- vvt1..-lll( of lif'e f. de<-h, t 1/ Ji"~ jol{d i'lllll1"1 p~_,,p{e, worl.l widv. if1.1:)" bw.u:ic,• 

• f'U:Jh2 Stt A1md1H>· 

Signed this __ 4_'1 ___ day of_~fl:-+/J_r1_/ ____ _ ,20~ 

VERIFICATION 

State of -------------~ 

County of __________ ~ 

(Signature of plaintiff or 

pla:intilffs) 

Duly sworn, under oath, says: that he is the plaintiff in this action and knows the content 

of the above complaint; that it is true of his ovvn knowledge, except as to those matters 

that are stated in it on his information and belief, and as to thos_e matters he believes to be 

true. 

(Signature of affiant-plaintiff) 

Case 0:20-cv-60882-WPD Document 1 Entered on FLSD Docket 05/01/2020 Page 7 of 8
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Case 0:20-cv-60882-WPD Document 1 Entered on FLSD Docket 05/01/2020 Page 8 of 8