FORM TO BE USED BY FEDERAL INMATES IN FILING A CIVIL ACTION UNDER 28 USC § 1331 OR § 1346 REVISED 8/05

IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF TEXAS

DIVISION

l ferl igg.

GAi C-C E.

(Enter above the full name and inmate nu ber

of each plaintiffin this action)

VS.

WhS 

Case No. J 

(Clerk will assign the number)

/ I l i 6 -.';b I

(Enter above the full name of each defendant in this action).

I. PREVIOUS LAWSUITS:

A. Have you filed any other lawsuits in state or federal court dealing with the same

facts involved in this action or otherwise relating to your imprisonment?

B. If your answer to "A" is "yes," describe each lawsuit in the space below. (If there is more than one

lawsuit, describe the additional lawsuits on another piece of paper, giving the same information.)

3. Court: (If federal, name the district; if state, name the county.) 

4. Docket Nu ber: 

5. Name of judge to whom case was assigned: 

6. Disposition: (Was the case dismissed, appealed, still pending?)

7. Approximate date of disposition: 

1

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II. PLACE OF PRESENT CONFINEMENT: F<C Al>/HCA)r 

III. EXHAUSTION OF GRIEVANCE PROCEDURES:

Pursuant to 42 U.S.C. § 1997e(a), exhaustion of administrative remedies is required prior to initiating civil rights

action or Federal Tort Claims Act lawsuit. Copies of all grievances, ppeal and responses must be submitted to verify

exhaustion. Failure to demonstrate exhaustion may be grounds for ismissal. The rules for federal prisoners are found at

4 C.F.R. §§ 542.10, et seq.

1. Informal Grievance

a. Did you submit an informal grievance

If so, you must attach a copy of the grievance and response.

/yes 

b. If not, then why not?

U C eitr M /YbM

2. Formal Grievance

a. Did you submit a formal grievance (BP-9)? YES NO

If so, you must attach a copy of the grievance and response.

b. If not, then why not?

3. Appeal to the Regional Director of the Bureau of Prisons

a. Did you timely submit an appeal to the Re ional Director (BP-10)? YES r NO

If so, you must attach a copy of the appeal and response.

b. If not, then why not? .. 

4. Appeal to the General Counsel of the Bureau of Prisons

a. Did you timely submit an appeal to the General Counsel of the Bureau of Prisons (BP-11)? YES NO 

If so, you must attach a copy of the appeal and response.

b. If not, then why not?

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IV. PARTIES TO THIS SUIT:

A. Name and address of each plaintiff: 

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Case 1:23-cv-00049-MJT-ZJH Document 1 Filed 02/01/23 Page 2 of 6 PageID #: 2
B. Full name of each defendant, his official position, his place of employment, and his full m iling address.

If you are bringing a civil rights lawsuit against federal employees, then your lawsuit should be filed pursuant to 28 U.S.C. §

1331. If you are bringing a Federal Tort Clai s Act lawsuit under 28 U.S.C. § 1346, then the only defendant will be the United

States of America. I .

Defendant # 1: ( P) (pTA ila c.i} i -. I"': '-TU': '.' 

Briefly describe the ct(s) or omission(s) of this defendant which you claimed harmed you.

Defendant #2: 'Kuc lE-. C AnO 

Briefly describe the act(s) or o ission(s) of this defendant which you claimed harmed you.

Defendant #3: _ _

Briefly describe the act(s) or omission(s) of this defend nt which you claimed harmed you.

Defendant #4: 

Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you.

i c Ihi' 

V. STATEMENT OF CLAIM:

State here in a short and plain statement the facts of your case, that is, what happened, where it happened, when it

happened, and who was involved. Describe how each defendant is involved. Do not give any legal arguments or cite

any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate

paragraph. Attach extra pages if necessary, but remember that the complaint must be stated briefly and concisely. IF

YOU VIOLATE THIS RULE, THE COURT MAY STRIKE YOUR COMPLAINT.

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Case 1:23-cv-00049-MJT-ZJH Document 1 Filed 02/01/23 Page 4 of 6 PageID #: 4
D. If your answer is "yes", give the following information for every lawsuit in which

warning was i posed. (If more than one, use another piece of paper and answer

the same questions.)

1. Court that imposed warning (if federal, give the district and division): 

2. Docket Number: 

Signed this

3. Approximate date warnings were imposed: 

(date)

day of

(molith)

(Signature of each plaintiff)

I DECLARE (OR CERTIFY, VERIFY OR STATE) UNDER PENALTY OF PERJURY THAT THE FOREGOING

(Signature of each plaintiff)

WARNING: The Plaintiff is hereby advised any false or deliberately misleading information provided in response to the

followin questions ill result in the imposition of sanctions. The sanctions the Court may impose include, but are not

limited to monetary sanctions and/or the dismissal of this action with prejudice.

5

Case 1:23-cv-00049-MJT-ZJH Document 1 Filed 02/01/23 Page 5 of 6 PageID #: 5
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FEB 0 1 2023

CLERK U.S. DISTRICT COURT

RECEIVED

NORTH HOUSTON TX 773 

C U fcS ECT

E o 5~n?&<£1

C r c/r// TX

EASTERN DIST ICT OF TEXAS

BEAUMONT, TEXAS

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Case 1:23-cv-00049-MJT-ZJH Document 1 Filed 02/01/23 Page 6 of 6 PageID #: 6