UNITED STATES DISTRICT COURT 

DISTRICT OF OREGON 

PORTLAND DIVISION 

(Enter ful/ name of plaintfjf(s)) 

Plaintiff(s), 

Defendant(s). 

I. 

Civil Case No.)'·lb-w-G8o-/+C 

(to be assigned by Cle_rkofthe Court} 

PRISONER CIVIL RIGHTS 

COMPLAINT 

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

prisoner? 

NoD 

B. If your aoswer to A is yes, how maoy? 2. . Describe the lawsuit(s) fu the 

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

another piece of paper, using the same outline.) 

I. Parties to the previous lawsuit: 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page I 

Form39.010 

Case 2:16-cv-00680-AC Document 2 Filed 04/18/16 Page 1 of 7
Defendant(s):,,Qi;., ell1'o1f-8/Af6Je· l Qg, Tliorrw> 8Rr,;,1QI / 

~AA11 :r-fll(t,t1~ etl!~ fJ._t,J,-lcaK I 

2. Court: [/,$, f;)j('Ukoup-r. 67.~r; lzf {)Rftt?~, tg,1pk/(;fa) Piv1.'fr'O;J 

3. Docket Number: :z.: 17- c.__1J-C!1t{'//$f--&Cjf1r3-c6·o::Ffl/S-A0 

4. Name of judge to whom case was assigned: tfco:.'l lilf-= 

~ 

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

6. Approximate date of filing: -11~-~l,,.,t._-_,,_l_,2._~-------

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

II. 

A. Place of confinement: S~ !!?1ltll Cdl?flt:Cf(l:fMf 7/1gT?lh W 

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

Yes~ NoD 

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

Ye~· No0 . 

If your answer is no, explain why not: 

D. Is the grievance process completed? 

Ye~ No0 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 2 

Form39.010 

Case 2:16-cv-00680-AC Document 2 Filed 04/18/16 Page 2 of 7
Ill. 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: VRmcs· LtJ?or lfeMs;/tf/W 

Security Identification No.: -'11'-'Z-~f fr~9~0_5,,__ _________ _ 

Address: 7..77 ~]8,t11,7&!J)_ ./lJm 

&rAJ?;..J>;hif'cdi.I 1"1r;11~ff1;.5 

(In item B, place the full name of each defendant, his/her official position, and his/her place 

of employment. 

B, Defendant TkofllM' .8Pd; 7fi f is employed as rf2ot:.T& R_ 

at__,_-A..1.-<-"'==--------------------

Defendant :hJt;»Al £/!r FJ'~rJ((lis employed a~O a c.. 712/;L 

atS J(C'¥ 

DefendantGwaJ, <fulfo/( 

at C 

DefendantSTcve .S'br.: /7/iJ.1 

' 

Defendant 4,. {IC/tJ'.:df?i 

at;LR_c<r:-

is employed as /:2ac78p; 

is employed as [2e; <el"'e>g:_ 

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

CIVIL RIGl)TS COMPLAINT 

Revised: April 24, 2008 

Page 3 

Form39.010 

( 

Case 2:16-cv-00680-AC Document 2 Filed 04/18/16 Page 3 of 7
IV. STATEMENT OF CLAIM 

Claim I 

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 necessary to give any legal 

arguments or cite any cases or statutes.) 

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 

Fo1m 39.010 

Case 2:16-cv-00680-AC Document 2 Filed 04/18/16 Page 4 of 7
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.) 

Claim ill 

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 conductoccurred. It is not necessary to give any legal 

arguments or cite any cases or statutes.) 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 5 

Fonn39.010 

Case 2:16-cv-00680-AC Document 2 Filed 04/18/16 Page 5 of 7
(lfyou have additio11al claims, describe them 011 a11other piece of paper, usi11g the same outline.) 

V. RELIEF 

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

statutes. 

Signed this 1L- day of cyz f{I L , 2010. 

(Signature of Plaintijf(s)) 

CIVIL RIGHTS COMPLAINT 

Revised: April 24, 2008 

Page 6 

Fo1m39.010 

Case 2:16-cv-00680-AC Document 2 Filed 04/18/16 Page 6 of 7
CERTIFICATE OF SERVICE 

CASE NAME: James Leroy Herrington v. Dr. Jodean Elliott/Blakeslee 

CASE NUMBER: 

COMES NOW, James Leroy Herrington, and certifies the following: 

That I am incarcerated by the Oregon Depaitment of C01rections at Snake River Correctional 

Institution. 

That on the 11th day of April, 2016, I personally placed in the 

Correctional Institution's mailing service A TRUE COPY of the following: 

Motion to proceed In Forma Pauperis; Motion for Appointment of Counsel; Declaration in 

Supp01t of Motion for Appointment of Counsel; Civil Cover Sheet; 42 USC § 1983 Complaint; 

Six Month Inmate Trust Account Statement; Account Certificate 

I placed the above in a securely enclosed, postage prepaid envelope, to the person( s) 

named at the places addressed below: 

United States District Court 

Office of the Clerk 

District of Oregon 

Pendleton Division 

Suite 740 

1000 S.W. Third Avenue 

Portland, Oregon 

97204-2902 

Dated this 11th day of April, 2016 

Page 1 of 1 -Certificate of Service 

Respectfully Submitted 

James Leroy Herrington 

4218905 

777 Stanton Blvd. 

Ontario, Oregon 

97914-8335 

Form03.015 

Case 2:16-cv-00680-AC Document 2 Filed 04/18/16 Page 7 of 7