UNITED STATES DISTRICT COURT 

DISTRICT OF OREGON 

PORTLAI\'D DIVISION 

Civil Case No. 

(to be assigned by Cl~rk of the Court} 

11. 

(Enter full name of plaintiff(s)) 

-~ 

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v. c o.i'P 11/1'1 I/ c I tJ !1 f ;vol J 

(Enter full name of ALL defendant(s)) 

~- Defendant(s).J 

I. 

PRISOI\'ER CIVIL RIGHTS 

COMPLAINT 

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

B. 

. ? 

pnsoner. / 

Yes~ NoD 

If your answer to A is yes, how many? L . Describe the lawsnit(s) ill the 

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

another piece of paper, using the same outline.) 

1. 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 1 

Form 39.010 

Case 2:15-cv-00065-BR Document 9 Filed 03/02/15 Page 1 of 6
2. 

Name of judge to whom case was assigned: --7'[~)~/_'l_7_L__/_l! __ / 

3. 

4. 

5. Disposition (VI. r as the c:ase. di.· smissed? .Was it appealed? Is it still pepding?) 

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6. Approximate date of filing: <'~ (/1 J / -· / 2. 

7. Approximate date of disposition: ·-;:,() / l · ( 4 

A. Place of confinement: ------------------

B. Is there a prisoner grievance procedure in this institution? 

YesO;{ NoD 

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

Yes rd NoO 

If your answer is no, explain why not: 

D. Is the grievance process completed? 

Yesd NoO 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 2 

Fonn 39.010 

s 

J 

Case 2:15-cv-00065-BR Document 9 Filed 03/02/15 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 plaintiffs, if any.) 

(Jc.7vV \'f I c l A Name of plaintiff: 

Security Identificati_o_n_N_o_. :__ i_J_/_(",~/~5-<A:·~-. ~-·;_< _ _/ _____ _ 

Address: 7 Z 7 51<; ~ j..::~.¥ P J fj;) 

o .111 1-,,1 }7o' o 'R 'l Z'l I l-f 

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Defendant L __ /_J _____ is employed as-------

fil~~~_L__,~t_i_C._Jt~'~~~~~~~~'----~ 

/

·0 0 fJVlrC { / {Y{ f)cJ' Defendant ( l/ is employed as ______ _ 

at )~ fA(~J-t 

/! 1/J )t/!S /J-f (JC Defendant (/ V {/ ()/.<./ . is employed as __ L-____ _ 

at ' J',fi'_. c.~t ' -----~~--------------~ 

CIVIL RIGJ!TS COMPLAINT 

Revised: April 24, 2008 

Page 3 

Form 39.010 

Case 2:15-cv-00065-BR Document 9 Filed 03/02/15 Page 3 of 6
JV. STATEl\'.IBNT OF CLAIM 

Claim I 

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

violated. 

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

each defenda11t is involved and when the conduct occurred. It is not necessaJ)' to give any legal 

arguments or cite any cases or statutes.) 

c o/' /?,r/ /71// cc/ J f {vv;,1 l'l e 10iv-t·ej v I CJ I q frJ ·"1 Y 

v {' f __ _) ./ 

Claim II 

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 

Fonn 39.010 

Case 2:15-cv-00065-BR Document 9 Filed 03/02/15 Page 4 of 6
Supporting Facts: (State here as briefly as possible the facts of your case. Describe how 

each defendant is involved and v.;hen the conduct occwred. It is not necessmy to give any legal 

arguments or cite any cases or statutes.) 

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 the facts of your case. Describe how 

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

arguments or cite any cases or statutes.) 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 5 

Form 39.010 

Case 2:15-cv-00065-BR Document 9 Filed 03/02/15 Page 5 of 6
(If you have additional claims, describe them on another piece of paper, using the same outline.) 

V. RELIEF 

State briefly exactly relief you are seeking. }.fake no legal arguments. Cite no cases or· 

j)v( /ll/ r 

Cf/( ()Cit) 

L':7 ~, Signed this __ day of _________ , 2o_L? 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 6 

Form 39.010 

Case 2:15-cv-00065-BR Document 9 Filed 03/02/15 Page 6 of 6