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

IN THE UNITED STATES DISTRICT COURTy g DlSTR CT COURT,

FOR THE e, DISTRICT OF TEASKRN DISTRICT Ur ItXAS

DIVISION JUN 3 0 2023

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Plaintiffs Name arid ID Number gy

DEPUTY 

Place of Confinement

CASE NO. „ ' > s f * 1 2 3 4 '¦ 

(Clerk will assign the nu ber)

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Defendant s Na e and Address

Defendant’s Na e and Address

Defendant’s Na e an Address

( DO NOT USE ET AL. )

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 t pewritten. You, the plaintiff, must sign and declare

under penalt of perjur that the facts are correct. If ou need additional space, 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 sa e efendant, Rule 18, Federal Rules of Civil Procedure. Make a short and

plain st tement of our claim. Rule 8, Federal Rules of Civil Procedure.

4. When these forms are co pleted, mail the original and one cop to the clerk of the United States district court

for the appropriate district of Texas in the division here one or ore na ed defendants are located, or where the

incident giving rise to our claim for relief ccurre . 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 our unit

law librar . It is list of the Texas prison units indicating the appro riate district court, the division and an address

list of the divisional clerks.

1

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Case 6:23-cv-00324-JCB-KNM Document 1 Filed 06/30/23 Page 1 of 5 PageID #: 1
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 necessary funds to pay the fee in full at this time, you may request permission to procee 

in forma pauperis. In this event you must complete the application to proceed in forma pa peris, setting forth

. infor ation to establish your inability to re ay the fees and costs or give security therefor. You must also include

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

a plication to proceed in forma pauperis an the certificate o inmate trust account, also known as in forma

pauperis data sheet, from the law librar a your prison unit.

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

appeal i form pa peris, the prisoner shall be require 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 parti l

filing fee and monthl installments until the entire amount of the filing fee h s been paid by the prisoner. If you

sub it the application to proceed in for a pauperis, the court ill appl 28 U.S.C. § 1915 and, if appropriate,

ssess and collect the entire fi ling fee or an initial partial filing fee, then onthl installments from your inmate trust

account, until the entire $350.00 statutor filin fee has been pai . (The $50.00 administrative fee does not apply

to cases roceeding in forma pauperi .)

4. If ou inten to seek in for a pauperis status, do not sen your complaint without an application to proceed

in for pauperis and the certificate of inmate trust account. Complete all essential aper ork before submitting

it to the court.

CH NGE OF ADDRESS

It is your responsibility to infor the court of an change of address and its ef ective date. Such notice should be

marked 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 CHA GE OF ADD ESS a result in the dismissal

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

I. P EVIOUS LAWSUITS:

A. H ve you filed aw other lawsuit in state o federal court relating to our i prisonment? YES NO

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

la suit, escribe the additional lawsuits on another piece of paper, giving the same info mation.)

1. Approximate date of filing la suit: EX 

2. Parties io previous la suit:

Plaintiffis) yg., 

De fend an t( s) \ P -ww o2 . : 

3. Court: (If fe eral, name the district: if state, name the county.) 

4. Cause number: N - 

5. Na e of judge to who case as assigned: 

6. Dis osition: (Was the case dismissed, appealed, still pending?) kw - 

7. Approxi te date of dis osition: 

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Case 6:23-cv-00324-JCB-KNM Document 1 Filed 06/30/23 Page 2 of 5 PageID #: 2
II. PLACE OF PRESENT CONFINEMENT: c a- Of y*> \ t ?> .y

111. EXHAUSTION OF GRIEVANCE PROCEDURES:

Have you exhausted all steps of the institutional grievance procedure? . ES O

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

IV. PARTIES TO THIS SUIT:

A. ame and a dress of plaintiff: 

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B. Full name of each efendant, his official position, his place of emplo ment, an his full mailing address.

Defendant# 1: . 

Briefly escribe the act(s) or omission(s) of this defendant which you claime har e you.

Defendant# : - 

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

Defendant #3: 

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

Defendant #4 :y XFTTTTZIZITTZZZT~TrTZXZZZZZIIZZZZZZZZZZZI?ZIZZZZIZZZTTZTTrTTFTZ'' ZZ 

Briefl describe the act(s) or oniission(s) of this defendant which you clai ed harmed you.

Defendant #5 0 TZ Z

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

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Case 6:23-cv-00324-JCB-KNM Document 1 Filed 06/30/23 Page 3 of 5 PageID #: 3
V. STATEMENT OF CLAIM:

Stale here in a short and plain statement the facts of your case, th t is, what happened, here did it happen,

hen di it happen, and ho was involve . Describe ho e ch defendant is invol ed. You need not give

anv legal arguments or cite any cases or statutes. If you intend to allege a number of relate claims, number

an set forth each clai in a se arate paragr ph. Attach extra pages if necessary, but remember the

co plaint must be stated briefly an concisely. IF YOU VIOLATE THIS RULE, THE COURT MAY

STRIKE YOUR COMPLAINT

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VI. RELIEF:

State briefl exactly hat you ant the court to do tor you. Make no legal argu ents. Cite no cases or

statutes.

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VII. GENERAL BACKGROUND INFORMATION:

. State, in complete form, all na es ou have ever used or been known by including any nd all aliases.

V-.Fx g. W ca s-ss x r-a A- e k y. Tpx (t . L \ e. w x ) fexo K3 LX vQAcy

B. List all TDC.LCID identification numbers ou have ever been assigned and all other state or fe eral

prison or FBI numbers ever assigned to ou.

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VIII. SANCTIONS:

A. Have you been sanctioned b an court as a result of an la suit ou have filed? YES NO 

B. If your ans er is " es, ive the followin information for every la suit in hich sanctions were

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

I. Court that i osed sanctions (if federal, ive the district and division): — 

3. Approximate date sanctions were imposedi r TLZZffZirZZZZZTZZLTZZTTZZZTTZZZTTZZZZZZZZZZZl

4. Have the sanctions been lifted or other ise s tisfied? NG4

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Case 6:23-cv-00324-JCB-KNM Document 1 Filed 06/30/23 Page 4 of 5 PageID #: 4
C. Has any court ever warned or notifie you that sanctions could be imposed? YES , NO

D. If your answer is yes, give the following information for every la suit in which a arning was issued.

(I more than one, use another piece of aper and ans er the sa e questions.)

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

2. Case number: y 

3. Approximate ate warning as issued: — ~~~~ ' A

Executed on: a 

DATE

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(Signature of Plaintiff)

PLAINTIFF S DECLARATIONS

]. 1 declare under penalty of perjury all facts presente 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 y

current mailing address an failure to do so ay result in the dismissal of this l suit.

3. I understand I must exhaust all a ailable a ministrati e remedies prior to filing this la suit.

4. 1 understand I am rohibited from bringing an in forma pa peris lawsuit if I have brought three or more

civil actions or appe ls (from a ju g ent in a ci il action) in a court of the United States hile

incarcerated or etained in any facility, - hich lawsuits ere dismissed on the round they were

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

imminent danger of serious physical injury.

5. I understan even if I a allowed to proceed without prepay ent of costs. I am responsible for the entire

filing fee and costs assessed b the court, hich shall be deducted in accordance ith the law rom my

inmate trust account by my custo ian until the filing ee is p id.

Signed this~Tu g- W - day of L 

(Day) (month) (year)

(LQ. . W ft-t 5 A

(Si nature 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 ay i pose include, but

re not limited to, onet r s nctions nd the dismissal of this action with prejudice.

Rev. 05/15

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