PRJSONBR'S CIVIL 0BTS cOMPLA Nr (Rev. 05/2015) F I L E D 

IN THE UI STATES DLSTRICI' COURT 

FOR THE \cti DISThICT c MAY Z 8 2020 

A1L\t4V% o DIVISION 

CLK. U.S. DISTRICT CLK 

Plaintiff's Name and It) Number 

e1i( CiwL çin (\r . CcX T 11 -igM Place of Conemeut 

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Defendant's Nanand Address 

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Defendant' sNani and Address 

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Defbndant's Name andAddress 

(DO NOT USE "E AL?') 

INSTRUCTIONS - READ CAREFULLY 

NOTICE: 

Your complaint is subject to dismissal unless It conforms to these Instructions and this form. 

1. To start an action you must file an original and one copy of your complaint with the cowt You should keep 

a copy of the complaint for your own records. 

2. Your complaint must be legibly handwritten, in ink, or typewritten. You, the plaintift must sign and declare 

under penalty of perjury that the thota arc correct. If you need additional space, DO NOT USE ThERE VKRS SIDEOR B&CE SIDE OF ANY PAGE. ATI'ACH AN ADDITIONAL BLANK PAGE AND WRITE ON IT. 3. You must le a separate complaint for each claim you have unless the various chaims are all related to the same 

hicidentor issue or aie all against the same de1bndnt, Rule iS, Federal Rules of Civil Procedure Make a short and 

plain statement of your claim, Rule 8, Federal Rules of Civil Procedure. 

4. When these forms are. completed, mall the original and one copy to the clerk of the United States district court for the appropriate district of Texas in the division where one or more named defendants are located, or where the incident giving rise to your claim for relief occurred. If you are confined in the Texas Department of Criminal 

Justice, Correctional Institutions Division (TDCJ-CID), the list labeled as 9'ENIJE LISr' is posted in your unit 

law library. It is a list of the Texas prison units indicating the appropriate district court; the division and an address 

list of the divisional clerks. 

Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 1 of 12
FILING 'FEE AND INFOPJ(4 PAUPERIS (IFP) 

1. In order for your complaint to be filed, it must be accompanied by the statutory filing fee of $350.00 plus a administrative fee of $50.00 for a total fee of $400.00, 

2. If you do not have the necessary fluids to pay the foe in full at this time, you may request permission to procee mfonnapaiçens in this event you must complete the application to proceed Informapauperr, setting forti Information to establish your friability to prepay the fees and costs or give security thereflr. You must also lnc1ud a current six-month history ofybur inmate trust accopnt If you are an Inmate in ThCI-CID, you can acquire tIn application to proceed In fon,za pauperLv. and the certificate of inm2te trust account;, also known as in ftnn parqerLs data sheet fiom the law library at your prison unit 

3. The Prison Litigation Reform Act of 1995 (PLRA) provides "... If a prisoner brings a civil action or flies an 

appeal frrftnnapaqerr,. the prisoner shall be required to pay the full amount of a filing fee." See 28 U.s.c. 1915. Thus, the court is required to assess and, when funds exist;, collect, the entire filing fee oran initial partial filing fee and monthly installments until the entire amount of the filing fee has been paid by the prisoner. If you submit the application to proceed apariperLc, the court will apply 28 U.s.c. § 1915 and, If appropriate, assess and collect.the idire fihingfec oran initial partial filing fee, then monthly installments flom your inmate trust 

account until the entire $350.00 statutory filing fee has been paid. (The $50.00 adniinisfrative fee does not apply to cases proceeding hzjbrmapauperls.) 

4. If you Intend to seek in jbr,na parqwL statUs, do not send your complaint without an application to proceed mjrapauperzs and the certificate of inmate trust account Complete all essential paperwork before submitting ittothe court. 

CRANGE OP ADDRESS 

it is your responsibility to inform the court of any change of address and its effective date. Such notice should be marked "NOTICE TO TUE COIJRT OF CHANGE OF ADDRESS" and shall not include any motion for any other relief Failure to file a NOTICE TO ThE COURT OF CHANGE OF ADDRESS may result In the dismissal of your complaint pursuant to Rule 41(b), Federal Rules of Civil Procedure 

I. PREVIOUS LAWSUTI'S: 

A. Rave you filed any other Lawsuit in state or federal courtrelating to yourimprisonment?YESNO 

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 pece of paper, giving the same information.) 

I. Appromate date of filing lawsuit: \tc io S 

2. PartIes to previous lawsuit: 

PIainttfls) t\ji %c;% (j i't( ( 4 LJA1 

3. Court (If federal, name the district; if state, name the county.) \o.$ )k'J\.L. 

4. Cause number: - - 1 / ¶ 

5. Name ofjudge to whom case was assigned; tk\&r.. * 

6. DispositIon: (Was the case dismissed, appealed, still pending?) f?'rvL', 

7. Apprôxtmatedate of disposition: it44- 

Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 2 of 12
IL PLACE OFPRESENTCONFINEMENT: A Ctvt 

LU. EXHAUSTION OF GRIEVANCE PROCEDURES: 

Have you exhausted all steps of the Institutional grievance procedure? YES N( 

Attach a copy of your final step of the grievance procedure with the response supplied by the institution 

IV. PARTIES TO IHIS SUiT: 

A. NameandaddrcssofpLaintifi tt) 

2(S V 1(2c 

B. Full name of each defendant, his omcial position, his plaoqof employment, and his full mailing addxess. 

4- (.j) 

Defdant#l: L\c ji cc b\\*f (c Ac- vsMr) 2CL Cr v 

'Briefly describe the act(s) or omission(s) of this defendant which you claimed banned you. 

' 

Defendant#2: AL 2rC %.1. C.jX kiw iJr7 

Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. 

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Defendaut#3: 2e&c Cv MU Ce4c 

2A1 (t-.u.-%1j\. Sc c. o 

Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. 

SQ fict& 

Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. 0.x. 

Briefly describe the act(s) or omission(s) of this deflant which you claimed banned you. 

3 

Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 3 of 12
V STATEMENT OF CLAIM: 

State hero i a short and plain statement the facts of your case, that is, what happened, where did it happen when did it happen, and who was involved. Describe how defendant is involved. You need not iv 

any legal argumtsor cite any cases or stetute. If you intend to allege a number of related claims, numbe: 

and set forth each claim in a separate paragraph. Attach extra pages if necessary, but remember th complaint must be stated bnetly and concisely IF YOU VIOLATE THIS RULE, THE COURT MA STRTZE YOUR COMPLAINT. 

I, 

Vi. RELIEF: 

State briefly exactly what you want the court to do for you. Make no Legl arguments. Cite no cases or 

statutes. 

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VII. GENERAL BACKGROUND ThFORMATION:. 

A. State, In complete form all names you have ever used or been known by including any and all aliases. 

B. List all 1DCJ-CD identification numbers you have ever been assigned and all other stateor federal prison or FBI numbers ever assigned to you. 

KtW Lk t btt1 

VJIL SANCTIONS: 

A. Have you been sanctioned by any court as a result of any lawsuit you have filed? _YES JNO 

B. if your answer is "yes," give the following information for every lawsuit in which sanctions were 

imposed. (If mote than one, use another piece of paper and answer the same questions.) 

1. Court that imposed sanctions (if federal, give the district and division):______________ 

2. Case number 

3. Approxrntedatessnctionswereimposed: 

4. Have the sanctions been lifted or otherwise satisfied? YES NO 

4 

Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 4 of 12
C. flas any court ever warned or notified you that sanctions could be imposed? 

D. If your answer is "yes,'1 give the following iufonnalion for every lawsuit in which a warning was issue (If more than one, use another piece of paper and answer the same questions.) 

1. Court that issued warning (if federal, give the district and division): 

2. Case 

3. Approximate date warning was 

PLAINFIFF'S D1CLARA11ONS 

79 

(Signature of Plaintift) 

1. 1 declare under penalty of perjury all facts presented In this complaint and attachments thereto are true and correct 

2. 1 

current 

understand, 

mfling 

If Ism released or transferred, it is my responsibility to keep the court informed of my address and failure to do so may result in the dismissal of this lawsuit 

3. 1 understand! must exhaust all available administrative remedies prior to filing this lawsuit 4. uudeistand I am prohibited from bringing an informapauperis lawsuit if I have brought three or more civil actions or appeals (from ajudgnient In a civil action) in a court of the United States while incarcerated or detained in any facility, which lawsuits were dismissed on the ground they were frivolous, malicious, or failed to state a claim upon which relief may be granted, unless I am under inunincnt danger of serious physical injury. 

5 I understand even iflani allowed to proceed without prepayment of costs, lam respousthie for the entire filing 

inmøtC 

ftc 

trust and coals assessed by the court, which shall be deducted in accordance with the law from my account by my custodian until the filing fee is paid. 

Signed this day of ) sOJ ,20 2 

(Day) (month) (year) 

Ijji"i.L)4 

WA11'11NG: 

above 

Plaintiff Is advised any false or deliberately misleading hafonnatlou provided In response to the are not 

questlois may result In the Imposition of sanctions. The sanctions the court may lmpo3e include, but limited to, monetary sanctions and the dismissal of this action with prejudice. 

Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 5 of 12
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NAME '_ $iD#' \ DOB 

INCIDENT HOUSING DATEi2.f40 DATE1TIME -L utirr 3- 1 

4 State incident or problem as deady ar1 brief ty as posstbie (Usa additional forms or pt.afr paper if necessary). Place 

form in tht box murked Gr1vanpe the unit moll box or giva to LhrIng Unit Ortflcer You will receive your r3cnsu 

througli tile malt You can obIan addWorat gdevanec forms from Living Untt Qffoe Do not attach ny Items or mtrIais to grievance form. 

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FOR OICIAL USE ONLY * DO NOT WR4TE BELOW THIS UNE 

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INVESTIGATED B? 5'L L L 

REFERRED TO S REJECTED lnctuds rational, for wjoct In response) f "' ce Sejr, 

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PINK COPY RETAINED BY INMATE FORM 351-44(8111) 

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Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 9 of 12
NAME \A\( tft SID # 2. 1 008 I1 j 

C1 INCIDENT S HOU8IN 

DATE___________ DATE/TIME I!L)jL') UNIT ___________ 

Slate Incident or prcbtem s cIezry a briefly as posslbie.(Use addilionsi focms r pLain paper If neoee. ) PIEce corm in U, box narked Gilevarme) the unit mIt box or glv to LIvlzig Unit Olf1cer You will receive your reouse 

through the mall. You oan obtalx actditlorml gderance (orms from LlvIn Unit Offfor. Do nol attach wy Items or 

materials to grlvunc form 

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Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 10 of 12
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S S BEXARCOUN1YAPULTDETENTIONCEN1tRSS:,S: 

1NMATES GREVANE-FORM 

NAME SID #,. 104 DOB ___ 

DATE L 

INCIDENT 

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S S - State incklent or problem as clearly and briefly as possible (use additional forms or plain paper If necessary) P)ace 

form In the box marked Grievance, the unit maN box or give to Living Unit Officer You wilt receIve your response through 

the man. You can obtain afdIttonai grievance forms from Living Unit Officer Do not attach any items or materials to 

grievance form. - 

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Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 11 of 12
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Case 5:20-cv-00652-DAE Document 1 Filed 05/28/20 Page 12 of 12