PRISONER S CIVIL RIGHTS COMPLAINT (Rev. 05/2015)

IN THE UNITED STATES DISTRICT COURT ~ . T . 

FOR THE 

I

Plaintiff s Name and ID Number

DISTRICT OF TEXAS

DIVISION

ET/

DEPUTY

casenoV TVNvZ

(Clerk will assign the number)

v.

Defendant s Name and Address

Defendant’s Name and Address

Defendant’s Name and Address

(DO NOT USE ETAL. )

INSTRUCTIONS - READ CAREFULLY

NOTICE:

Your complaint is subject to dismissal unless it conforms to these instructions and this form.

1. To start an action you must file an original and one copy of your complaint with the court. You should keep

a copy of the complaint for your own records.

2. Your complaint must be legibly handwritten, in ink, or typewritten. You, the plaintiff, must sign and declare

under penalty of pe jury that the facts are correct. If you need additional space, DO NOT USE THE REVERSE.

SIDE OR BACKSIDE OF ANY PAGE. ATTACH AN ADDITIONAL BLANK PAGE AND WRITE ON IT.

3. You must file a separate complaint for each claim you have unless the various claims are all related to the same

incident or issue or are all against the same defend nt, Rule 18, Federal Rules of Civil Procedure. Make short and

plain statement of your claim, Rule 8, Federal Rules of Civil Procedure.

4. When these forms are completed, mail the original and one copy to the clerk of the United States district court

for the appropriate district of Texas in the division where one or more named defendants are located, or where the

incident giving rise to your claim for relief occurred. If you are confined in the Texas Department of Criminal

Justice, Correctional Institutions Division (TDCJ-CID), the list labeled as VENUE LIST is posted in your unit

law library. It is a list of the Texas prison units indicating the appropriate district court, the division and an address

list of the divisional clerks.

1 Rev. 05/15

Case 6:23-cv-00512-JDK-JDL Document 1 Filed 10/18/23 Page 1 of 7 PageID #: 1
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FILING FEE AND IN FORMA PAUPERIS (IFF)

1. In order for your complaint to be filed, it must be accompanied by the statutory filing fee of $350.00 plus an

administrative fee of $50.00 for a total fee of $400.00.

2. If you do not have the necessaiy funds to pay the fee in full at this time, you may request perm i ssi on to proceed

in forma pauperis. In this event you must complete the application to proceed i for a pauperis, setting forth

information to establish your inability to prepay the fees and costs or give security therefor. You must also include

a current six-month histoiy of your inmate trust account. If you are an inmate in TDCJ-CID, you can acquire the

application to proceed in forma pauperis and the certificate of inmate trust account, also known as in for a

pauperis data sheet, from the law library at you prison unit.

3. The Prison Litigation Reform Act of 1995 (PLRA) provides ... if a prisoner brings a civil action or files an

appeal in forma pauperis, the prisoner shall be required to pay the full amount of a filing fee. See 28 U.S.C.

§ 1915. Thus, the court is required to assess and, when funds exist, collect, the entire filing fee or a initial partial

filing fee and monthly installments until the entire amount of the filing fee has been paid by the prisoner. If you

submit the application to proceed in for a pauperis, the court will apply 28 U.S.C. § 1915 and, if appropriate,

assess and collect the entire filing fee or an initial partial filing fee, then monthly installments from you inmate trust

account, until the entire $350.00 statutory filing fee has been paid. (The $50.00 administrative fee does not apply

to cases proceeding in forma pauperis.)

4. If you intend to seek in forma pauperis status, do not send your complaint without an application to proceed

in forma pauperis and the certificate of inmate trust account. Complete all essential paperwork before submitting

it to the court.

CHANGE OF ADDRESS

It is your responsibility to inform the court of any change of address and its effective date. Such notice should be

marked NOTICE TO THE COURT OF CHANGE OF ADDRESS and shall not include any motion for any

other relief. Failure to file a NOTICE OF THE COURT OF CHANGE OF ADDRESS may result in the dismissal

of your complaint pursuant to Rule 41(b), Federal Rules of Civil Procedure.

I. PREVIOUS LAWSUITS: I

A. Have you filed any other lawsuit in state or federal court relating to your imprisonment? J YES NO

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.)

1. Approximate date of filing lawsuit: ) A 

2. Parties to previous lawsuit:

Plaintif s) 

Defendan s) ( OK >T'

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

4. Cause number: 

5. Name of judge to whom case was assigned: v 

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

7. Approximate date of disposition: c | 

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Case 6:23-cv-00512-JDK-JDL Document 1 Filed 10/18/23 Page 3 of 7 PageID #: 3
II. PLACE OF PRESENT CONFINEMENT: J

III.

IV. PARTIES TO THIS SUIT:

B. Full name of each defendant, his official position, his place of e ployment, and his foil mailing address.

Defendant #1: C

Briefly describe the act(s) or omission(s) of this defendant which

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

. r ft \ x . .

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

Defendant #4: S

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

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

EXHAUSTION OF GRIEVANCE PROCEDURES:

Have you exhausted all steps of the institutional grievance procedure? YES NO

Attach a copy of your final step of the grievance procedure with the response supplied by the institution.

3

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Case 6:23-cv-00512-JDK-JDL Document 1 Filed 10/18/23 Page 4 of 7 PageID #: 4
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V. STATEMENT OF CLAIM:

State here in a short and plain statement the facts of your case, that is, what ha pened, where did it happen,

when did it happen, and who was involved. Describe how each defendant is involved. You need 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 the

complaint must be stated briefly and concisely. IF YOU VIOLATE THIS RULE, THE COURT MAY

STRIKE YOUR COMPLAINT.

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VI. RELIEF:

State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or

statutes.

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VII. GENERAL BACKGROUND INFORMATION:

A. State, in complete form, all names you have ever used or been known by including any and all aliases.

B. List allTDCJ-CID identificaiton numbers you have ever been assigned and all other state or federal

prison or FBI numbers ever assigned to you.

I) 1 > 

VIII. SANCTIONS: 

A. Have you been sanctioned by any court as a result of any lawsuit you have filed? YES NO 

B. If your answer is yes, give the following information for every lawsuit in which sanctions were

imposed. (If more than one, use another piece of paper and answer the same questions.)

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

2. Case number: . -

3. Approximate date sanctions were imposed: 

4. Have the sanctions been lifted or otherwise satisfied? YES NO 

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Case 6:23-cv-00512-JDK-JDL Document 1 Filed 10/18/23 Page 6 of 7 PageID #: 6
C. Has any court ever warned or notified you that sanctions could be imposed? YES NO 

D. If your answer is yes, give the following information for every lawsuit in which a warning was issued.

(If more than one, use another piece of paper and answer the same questions.)

Executed on: 

DATE

2.

3.

Court that issued warning (if federal, give the district and division): 

Case number: 

Approximate date warning was issued: 

c w 

(Signature of Plaintiff)

PLAINTIFF S DECLARATIONS

1. I declare under penalty of perjury ll facts presented in this complaint and attachments thereto are true

and correct.

2. I understand, if I am released or transferred, it is my responsibility to keep the court informed of my

current mailing address and failure to do so may result in the dismissal of this lawsuit.

3. I understand I must exhaust all available administrative remedies prior to filing this lawsuit.

4. I understand I am prohibited from brining an in forma pauperis lawsuit if I have brought three or more

civil actions or appeals (from a judgment in a civil action) in a court of the United States while

incarcerated or detained in any facility, which lawsuits were dismissed on the ground they were

frivolous, malicious, or failed to state a claim upon which relief may be granted, unless I am under

imminent danger of serious physical injury.

5. I understand even if I am allowed to proceed without prepayment of costs, I am responsible for the entire

filing fee and costs assessed by the court, which shall be deducted in accordance with the law from my

inmate trust account by my custodian until the filing fee is paid.

Signed this day of , 20 3

(Day) (month) (year)

(Signature of Plaintiff)

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

above questions may result in the imposition of sanctions. The sanctions the court may impose include, but

are not limited to, monetary sanctions and the dismissal of this action with prejudice.

5

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