FIL£D23 .JUN '1510:51USDC·ORP 

CIVIL RIGHTS ACT, 42 U.S.C.§ 1983 

In the United States District Court 

Plaintifrs Information ;1._ ~ /5- ~v- /13 5 - M 0 

Prisoner No. 1-.l '1L. O··HO 

rJ..-> '"71 Streett.\7oo p1l r e<> r p1-. City ~ rr\ b: State c.ct. 

Are there additional plaintiffs 0 Yes "JZ'No v 

If yes, any additional plantiffs to this action should be listed on a separate 81 /2" x I I" sheet of paper and securely 

attached to the back of this complaint. You must provide names, prisoner numbers and addresses for a ll plaintiffs 

Defendant's Information 

Name ie a~Jh-c Any}::kmofj Position Ouf".)~ H-c,c.bhc\n~l 

Lj(('..C \)lonur PL 

Street I P.O. Box City ?eodldcn State OK Zip tllSO) 

Personal Ca Both 

Are you suing more than one defendant? J8 Yes DNo 

If yes, any additional defendants to this action should be listed on a separate 81 /2" x I I" sheet of paper and securely 

attached to the back of this complaint. You must provide names, positions, current addresses and the capacity 

( personal, official or both) in which you are suing them. 

(Umatilla County Jail 4 700 NW Pioneer Place Pendleton, OR 97801) 

Case 2:15-cv-01135-MO Document 1 Filed 06/23/15 Page 1 of 7
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Lt7oo1>w~r pL ~vv:lk\-on, OK.. ~~~01 

T C..Y\1"\ 5u.t h %- Th I ~ rl ~ f~l'ld c:~n \- I n h.R,.;- ·• orr' c.\. cJ C.O..p~ h) 

Case 2:15-cv-01135-MO Document 1 Filed 06/23/15 Page 2 of 7
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 txJ 

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

If your answer is no proceed to part II. 

1. Docket number -----------------------------------

2. Name of Court ___________ _ 

3. Parties ( Caption or name of case ) __________________ _ 

4. Disposition ______________________ _ 

1. Docket number -----------------------------------

2. Name of Court ____________________ _ 

3. Parties (Caption or name of case) __________________ ~ 

4. Disposition ______________________ _ 

(Umatilla County Jail4700 NW Pioneer Place Pendleton, OR 97801) 

Case 2:15-cv-01135-MO Document 1 Filed 06/23/15 Page 3 of 7
FILED·,..o·:o Jllt" '151 -5 ....J ' 1 0: 11.JSDC·ORP 

II. Statement of Claim 

State here, as briefly as possible, the facts of your case. Describe how each 

defendant is involved. Include the names of other people, dates and places involved in the 

incident. Do not give any legal arguments or cite any cases or statutes. If you intend to allege 

several related claims, number and set froth each claim on a separate 8112" x 11 " sheet of paper 

and securely attach the paper to the back of this complaint. 

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V. Relief 

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

I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and 

correct. 

Executed on lp- \'~- \5 C\ fjfua Signature of Plainti f 

I 

(Umatilla County Jail4700 NW Pioneer Place Pendleton, OR 97801) 

Case 2:15-cv-01135-MO Document 1 Filed 06/23/15 Page 4 of 7
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Case 2:15-cv-01135-MO Document 1 Filed 06/23/15 Page 5 of 7
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Case 2:15-cv-01135-MO Document 1 Filed 06/23/15 Page 6 of 7
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