UNITED STATES DISTRICT COURT 

DISTRICT OF OREGON 

PORTLAND DIVISION 

Plaintiff(s), 

I. 

Civil Case No. 

{to be assigned by Clerk of the Court) 

PRISONER CIVIL RIGHTS 

COMPLAINT 

A. Have you brought any other action or appeal in a comt of the United States while a 

prisoner? 

YesD N~ 

B. If your answer to A is yes, how many? . Describe the lawsuit(s) in the 

space below. (Jfthere is more than one lawsuit, describe the additional lawsuits on 

another piece of paper, using the same outline.) 

I. Parties to the previous lawsuit: 

Plaintiff(s): -----------------

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Pagel 

3:15-cv-00161-JO

Case 3:15-cv-00161-JO Document 2 Filed 01/29/15 Page 1 of 6
Defendant(s): -----------------

2. Court: --------------------- 3. Docket Number: ----------------~ 

4. Name of judge to whom case was assigned: _______ _ 

5. Disposition (Was the case dismissed? Was it appealed? Is it still pending?) 

6. Approximate date of filing: 

7. Approximate date of disposition: ------------

A. 

l»l'l.Yh~,i~·hrri CG'u.«f'1 J11'1 L 

;z I!) U $ !Al fYC l'\ M !:i 

Place of confinement: · r · 1 I -1.~f,~\ ~l s-+p-c,_rc_o_,~C.J~. r-.e~,-,o-'1-" -.-q-1-1-·1./3 ~¢ 3 g ~1 '1 

Is there a prisoner grievance procedure in this institutiefn? 

Yes'ryl' ,t£l{ NoO 

C. Have you filed a grievance concerning the facts relating to this complaint? 

NoO 

If your answer is no, explain why not: 

D. Is the grievance process completed? 

Ye~ 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

NoO 

Page 2 

Case 3:15-cv-00161-JO Document 2 Filed 01/29/15 Page 2 of 6
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 plaintiffe, if any.) 

A. Name of plaintiff: DEl\ll\l 'ts ::Jf1~ Lu 11· R ~' e Al 

Security Identification No.: I Y - 14 () "5 

Address: WD-~J~~~ +-(j)'l Lo U.,{\:t~ ;Jfft L 1t' 5 kll 13'0 f\ M.S IV\ S 3 [;) Fi 1 l.:> bar o 1 C)r" e5 cr<1 ,, C/ ""'7 12 3 ·~ '3 g ~, 4 

(In item B, place thefi1/l name of each defendant. his/her official position, and his/her place 

of employment. 

B. ~~c't f=)s~·ls·+·c~-t 

at --""""'-'-'.e!...!..i"'-"Q-J......lL.'-'--~'-"""l..l....!....:'.:\..--~"""""''-. -----'--'.\ '_._,d=ls::...::..:bo r D ) () (fl.~ Cf'(I ' 

~---'-""'IJ.L.L.l _,_l=le~"·~c:....ffhmp1oyed as Ne,d·i ~cl fu·r '(;tiJ. I 

4·a'n c_ u.n"1 l •· thilsboco 10-:S6Y1. 

11~1\ll.~( 0. Sf)(!r°1ff: r1id . r r · L 

Defenctiillt iamployed as W {\ · 1._,.6 , ,c)'.'M, ..... 

at f\'t l(s~o'(o ( Oretto·yi ' LI 

Defendant ________ is employed as ______ _ 

at _____________________ _ 

Defendant ________ is employed as ______ _ 

at _____________________ _ 

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

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 3 

Case 3:15-cv-00161-JO Document 2 Filed 01/29/15 Page 3 of 6
IV. STATEMENT OF CLAIM 

Claim I 

State what right under the Constitution, laws, or treaties of the United States has been 

violated. 

11 

~1)tfra1 ~ ~h d ·, ? ~c-Lio ~ f~ M 1 CV/·eJ1 C a1 __:___i_f.:_:_<;, •I" t-A.l~ (' l \} {~ fii(•;ey<h f5 • 

Supporting Facts: (State here as briefly as possible the.facts of your case. Describe how 

each defendant is involved and when the cond11ct occ11rred. It is not necessmJ' to give any legal 

arguments or cite any cases or statutes.) 

State what right under the Constitution, laws, or treaties of the United States has been 

violated. 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 4 

Case 3:15-cv-00161-JO Document 2 Filed 01/29/15 Page 4 of 6
Supporting Facts: (State here as briefly as possible the facts of your case. Describe how 

each defendant is involved and when the conduct occurred. It is not necessary to give any legal 

arguments or cite any cases or statutes.) 

···l·e a.A +J,Cle 

Claim III 

State what right under the Constitution, laws, or treaties of the United States has been 

violated. 

Supporting Facts: (State here as briefly as possible thefOcts of your case. Describe how 

each defendant is involved and when the conduct occurred. It is not necessary to give any legal 

arguments or cite any cases or statutes.) 

-f±-cit:Wit;:e;,~~~---,&HF-+~/--t!l;;~~,...,_--i@#-~~ .. +J: vP¥1 'rH·t:?cJ 

:..:+3"'!___.!~4--'--+"Q..1....LL.-.:...L!i-~~~"-""""---'-'~i-+.:-~~0 tlvf tJ L}~ 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 5 

Case 3:15-cv-00161-JO Document 2 Filed 01/29/15 Page 5 of 6
(If you have atlditional claims, describe tltem 011 another piece of paper, using the same 011tli11e.) 

V. RELIEF 

State briefly exactly relief you are seeking. Make no legal arguments. Cite no cases or 

statutes. 

Signed this 2 7 day of 9'tltf'l 'LL wd 

G~l:~.n~~~ -~-F-N·~,._,,1j~·Lt~l.a~~ 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

(Signature of Plaintiff(s)) 

Page 6 

Case 3:15-cv-00161-JO Document 2 Filed 01/29/15 Page 6 of 6