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PRISONER S CIVIL RIGHTS COMPLAINT (Rev. 05/2015) EA’/, ' i " '

TEXAS

IN THE UNITED STATES DISTRICT COURT M 2 3 0 9

FOR THE s-t&p DISTRICT OF TEXAS

DIVISION

M a Cgb g TbCsi t a E

Plaintiffs Name and ID Number,

BY

deputy; 

~T Ot. uJF > Wb M t-Js y 

Place of Confinement

CASE NO. /

(Clerk will assign the nu ber)

Defendant s Name and Address

W VgfezS u

Defendant's Name an .Address

s-o> tWv < TV 

Defendant's Name and ddress

( DO NOT USE WT ALT)

INSTRUCTIONS - READ CAREFULLY

NOTICE:

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

1. To start an action you ust 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 leg bly handwritten, in ink, or typewritten. You, the plaintiff, must sign and declare

under penalty of perjury that the facts are correct. If you need additional sp ce, DO NOT USE THE REVERSE

SIDE OR BACK SIDE 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

inci ent or issue or are all against the same defendant, Rule 18, Fe eral Rules of Civil Procedure, Make a short and

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

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

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

incident givin rise to your clai 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

la library. It is a list of the Texas prison units indicating the appropriate istrict court, the division n an address

list of the divisional clerks.

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Case 6:23-cv-00316-JDK-KNM Document 1 Filed 06/23/23 Page 1 of 6 PageID #: 1
FILING FEE AND IN FORMA PAUPERIS (IFF)

1. In order for your complaint to be f led, it must be accompanied by the statutor filing fee o $350.00 plus an

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

2. If you do not have the necessary funds to pay the fee in full at this time, you may request permission to proceed

in forma pauperis. In this event you must co plete the application to proceed in forma pauperis, setting forth

. information to establish your inability to prepay the fees and cos s or give securit herefor. You must also include

a current six-month history of our inmate trust account. If ou are an in ate in TDCJ-C1D, you can acquire the

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

pauperis data sheet, from the law librar -' at your prison unit,

3. The Prison Litigation Reform Act of 1995 (PL A) providesif a prisoner brings a civil action or files an

appe l 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 o assess and, when funds exist, collect, the entire filing fee or an initial artial

filing fee and monthly installments until the entire camount of the filin fee h s been paid by the prisoner. If you

sub it the application to proceed in forma pauperis, the court vvi 11 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 fro your inmate trust

ccount, until the entire $350.00 statutory filing fee has been pai . (The $50.00 ad inistrative fee does not apply

to cases proceeding in forma pauperis.}

4. If ou 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

m rked NOTICE TO THE COURT OF CHANGE OF ADDRESS and shall not include any otion for any

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

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

I. PREVIOUS LAWSUITS:

A. Have you filed a y other lawsuit in state or federal court relating to your i prisonment? X YES NO

B. If your ans er to A is “yes, describe each la suit in the space belo . (If there is more than one

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

1. Approximate date of filing la suit: 

2. Parties to previous la suit:

Plaintif s) s. , 

Defendan s) Mae . ; .. , 

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

4. Cause nu ber: 

5. Name of judge to hom case was assigned: 

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

7. Approximate date of disposition: z. 

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Case 6:23-cv-00316-JDK-KNM Document 1 Filed 06/23/23 Page 2 of 6 PageID #: 2
11, PLACE OF PRESENT CONFINEMENT 

111. EXHAUSTIO OF GRIEVANCE PROCEDURES:

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

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

IV. PARTIES TO THIS SUIT:

A. Name and address of plaintiff:. LTtows 

'fNcwc-rcw-o ~TsxASSTO . 

B. Full name of each defendant, his official position, his place of employment, and his full . ailing address.

Defendant#I; Vex *; N .x

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

Defendant #2: U 3i, 3i..ss f-h fe

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

t 

\ V CL -J P>, o CE.

Defendant#?: cy». c_yy. yC ..u,fe.cu.vN...cu-.5 .j.. 

y 

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

A.AWw.. U. A twSL 

Defendant #4: - •- 

Briefl describe the act(s) or omission(s) of this defendant hich you clai ed har ed you.

Defendant#5; y~~~ ~ ~ ..ffTTZUBriefly describe the act(s) or omission(s) of this defendant hich you claimed harmed you.

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Case 6:23-cv-00316-JDK-KNM Document 1 Filed 06/23/23 Page 3 of 6 PageID #: 3
V. STATEMENT OF CL Al M:

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

when did it happen, and ho was involved. Describe how each defendant is involved. You need not give

anv egal arguments or cite an cases or st tutes. If you intend to allege a number of related claims, nu ber

and set forth each clai in se arate aragraph. Attach extra ages 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 argu ents. Cite no cases or

statutes.

VII. GENERAL BACKGROUND INFORMATION:

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

k Au UwUu botsg owsB. List all TDCJ-CID identification numbers ou have ever been assigned and all other state or federal

prison or FBI nu bers ever assigned to you.

VIII. SANCTIONS:

A. Have you been sanctioned by any court as a result of ny la suit ou h ve filed? YES yc. NO

B. If your ans er is yes, give the follo ing information for every la suit in hich sanctions ¦ ere

imposed. (If more than one, use another piece of paper and ans er the sa e questions.)

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

2. Case number: . - - 

3. Approximate date sanctions ere imposed:__ y 

4. Have the sanctions been lifted or other ise satisfied? ¥•&§- -x, O 

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Case 6:23-cv-00316-JDK-KNM Document 1 Filed 06/23/23 Page 4 of 6 PageID #: 4
C. Has any court ever warned or notified you that sanctions could be impose ? 

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

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

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

2. Case number: . -

3. Approximate date warning was issued: - - - - ¦ • • ¦ ¦ ¦ ¦ ¦ _

Executed on: l ~ A 

DATE

V, CXj-A-'A gw, \ lU, ,S> 

V.X <T-. w Q.s>--~-CW TAa c.Ac.v 

(Signature of Plaintiff)

PLAINTIFF S DECLARATIONS

1. I declare under penalty of perjury all facts presented in this complaint and attach ents thereto are true

and correct.

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

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

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

4. I understand I am prohibited from bringing an in forma pauperis la suit if I have brought three or ore

civil actions or appeals ( rom a judg ent in a civil action) in a court of the United States hile

incarcerated or detained in any facility, hich la suits ere dismissed on the ground they ere

frivolous, malicious, or failed to state a claim upon hich relief may be granted, unless I am un er

imminent danger of serious physical injury.

5. I understan even if I am allo ed to proceed ithout prepayment ofcosts, I am responsible for the entire

filing fee and costs assessed b the court, hich shall be deducted in accordance with the la fro my

inmate trust account by my custodian untifthe filing fee is paid.

Signe this day of , 20

(Dav) (month) (year)

Amy Q ex v CL Fl -T K CCM.X

(Signature of Plaintiff)

WARNI G: Plaintiff is advised an false or deliberately misleading i formation 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, monetar sanctions and the dismissal of this action with prejudice.

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