., 

•" " 

; 

1 

2 

3 

4 IN THE CIRCUIT COURT OF THE STATE OF OREGON 

5 FOR THE COUNTY OF \i\v..\lmornel.\,, 

6 

7 0-e..~ A\exand-cr &::\'IC\. ' 

Plaintiff, 

) 

) 

) 

) Civil No.---------

8 ) m~\\"" %- ()"'<'\~ 

) <..\\,f\\ (.C>\Y\~\{'\\-

9 ) Complaint cfl. ""fl''\\~' ~"""\\N\,W>A 

} "l:"\<r,~""''' J:n~\~W\ "\ e,n~'1J.\ ()<'<>~ 

10 \\u\\ \:ff,~ '!mcJ0 I'Cl,.: 

11 · 

12 

13 Defendant(s) 

14 

) 

) 

) 

) 

) 

) 

) vu. '/.\,(JG\~ 

1. 

15 PREVIOUS LAWSUITS 

16 A Have you begun other lawsuits in state or federal court dealin with the same facts 

17 involved in this action or otherwise relating to !your imprisonment? Yes L___) No ~ 

18 B. if your answer to A is yes, describe the lawsuit in the space below. If there is more than 

19 one lawsuit, describe the additional lawsuits on another piece of paper, using the same outline. 

20 Ill 

21 Ill 

22 Ill 

23 Ill 

24 Ill 

Page 1 of 5-Complaint Form 10.030 08/17/15 

Case 6:16-cv-00205-BR Document 2-1 Filed 02/03/16 Page 1 of 6
I 1. Parties to this previous lawsuit: 

2 Plaintiff(s): _____________________ _ 

3 

4 

5 Defendant(s): _____________________ _ 

6 

7 

8 2. Court (if federal court, name the district; if state court, name the county): 

9 

10 3. DocketNumber:. ______________________ _ 

11 4. Name of Judge to whom case was assigned: 

12 

13 5. Disposition (Was case dismissed? Was it appealed? Is it still pending?):. ___ _ 

14 

15 6. Approximate date of filing lawsuit:. ________________ _ 

16 7. Approximate date of disposition:. _________________ _ 

17 ~ 

18 (In item A below, place your name in the first blank and place your present address in the 

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

20 A. Name of Plaintiff: S?e~ ,,A\-ext\O{k ::'::..:x\cA 

21 Address: tJSC..t. Oe"'<' 9e1.<k:.. 'Or\\Je 'SE :'xt\em O? Q7-3(D 

22 

23 Ill 

24 Ill 

Page 2 of 5-Complaint Form 10.030 08/17/15 

Case 6:16-cv-00205-BR Document 2-1 Filed 02/03/16 Page 2 of 6
< 

• 

(In item B below, place the full name of the defendant in the first blank, his official 

2 postition in the second blank, and his place of employment in the third blank. Use item C for 

3 the names, positions, and places of employment of any additional defendants.) 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

B. 

C. 

A. 

B. 

C. 

D. 

E. 

/II 

is employed as 

Additional defendants: -----------------~-----

3. 

ADMINISTRATIVE REMEDIES 

Place of Confinement: t60:: 

~~~--------------------

Is there a prisoner grievance procedure in this institution? YES ( )(·) NO L_) 

Did you present the facts relating to your complaint in the state preson grievance 

precedure? YES L_) NO ()0 ) 

If your answer to C above is yes: 

1. \Vhat steps did you take? ____________________ _ 

2. \li'hat was the result? -----------------------

If your answer to C above is no, explain why not: 1'o\. J:f\vo\ve:s, CG"'~~x'"'"'\;:,1 \~'<\ \p 

Page 3 of 5-Complaint Form 10.030 08/17/15 

Case 6:16-cv-00205-BR Document 2-1 Filed 02/03/16 Page 3 of 6
' 

1 F. If there is no prison grievance procedure in the institution, did you complain to prison 

2 authorities? YES L_) NOL_) 

3 F. If your answere to Fis yes: 

4 1. V.'hat steps did you take? 

5 

6 2. \Nhat was the result? 

7 

8 4. 

9 STATEMENT OF CLAIM 

10 State here as briefly as possible the facts of your case. Describe how each defendant is 

11 involved. Include, also the names of other persons involved, dates, and places. Do not give any 

12 legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, 

13 number and set forth each claim in a separate paragraph. Use as much space as your need. 

14 Attach extra sheets if necessary. 

15 aW<c.\.,,,\9Q,!¥5 o:::. 5~\. c\o:~ en a,i1~\\y,m\ J:bL'<'-~\-& oiekAolam c1YXJ C>\-\\1. 0\<"e. Llw"". 

16 oo.'"11$.e::. &1 LJ11cl. ~+..- rw:.~ 

17 

18 

19 

20 

21 

22 

23 

24 

Page 4 of 5-Complaint Form 10.030 08/17/15 

Case 6:16-cv-00205-BR Document 2-1 Filed 02/03/16 Page 4 of 6
'· . , . ' < 

' 

1 s. 

2 RELIEF 

3 State briefly exactly what you want the comt to do for you. Make no legal argmnents. 

4 Cite no case or statutes. 

6 fk, l'\l., ~, ?< •• '- ~,.. 

~ I I 

7 

8 

9 

10 

11 

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

13 DATED this lo·\I... 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

Page 5 of 5-Complaint 

, 20 1,'!). 

Print Name: P-ew .Al-entvidv- ~ol< 

SID Nmnber: ~~~~~~~~~~ IS"'<-'?. f!o «1-

3405 Deer Park Drive, SE 

Salem, Oregon 97301 

Form 10,030 08/17/15 

Case 6:16-cv-00205-BR Document 2-1 Filed 02/03/16 Page 5 of 6
OREGON DEPARTMENT OF CORRECTIONS 

INMATE COMMUNICATION FORM 

To:'I~ ~ - .. JS-kla.v\~ Date:_· Cf~/_z__.s-+-ft-~------ · · aA ' 

State your issue in detail: :C tvcol;e, \:\v..y t:on.9 2'l,"cb1 Xnc «J U.(11 {t'> W'v4\e ~ i"' osP, :X: t.vYOl-e. 

(\ .;\few PmducJ: :t:ol-M. ~\;- qoss\'o\j ±k tc\/V\.'f?'l©j rno.y &r l\y;\¥ nD\- \-xive made Cl. Xle\ceaAf'. ~vYI 

my 1::deC1. WCl1> 1vs'D"°:J llooel "'>clWe2. \(\\-()Cl 'Gegr ~0/MI) ~1o'rtv- ~. fu,, ~mclwA· 01nol oil( 

Su.v..s..e..s &1 tYL(Ar\ce.\ 'Ol.Sc<\<Y\W'Or\(,v1,. e ff(}< cll'<£/1hoo\.'(I''"".) o-<\- rcccn'fl:'\\.n 

' e.c '" ,Y\\c. Clio~ ~1c.t\0\,'c. -emt\c"<'"-'Slwv~ 

C<u.€.\ cmol uf\\J,.'£\ f•mis\,~ a+kmpf qM av\Sp««y· :tba.1g.:i, CO..«fcic/\, Sic<Y\cJ-V-\ltr&or,\ J:b"'''-1 

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~\\ 'Q:-\-<n.\ ~ taw Cc':::. o. lY\1N1.oy O\Dora\. Oha.( l~o.l ~~S po1jr1 \r. fu\\ '"Cl TIYN-l(j l'lJQ!hY'-'[ 

o-\- .2'{ hw.rs M- ~<$<m}A.\- +o lo>e Pkcecl i" flat'\\-;~ bornlL o.cu»M o.\- 1,gJVi2ii.vo 

Inmate Committed Name (first middle last) 

Pe4r 

Response/Action Taken: 

Date Received: Referred To*: 

Date Answered: --------- Signature of Staff Member: 

'If forwarded, please notify the inmate 

Housing Unit 

CD 214 (12/04) 

Case 6:16-cv-00205-BR Document 2-1 Filed 02/03/16 Page 6 of 6