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KM 

WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Gary Jerome Harper, 

Plaintiff, 

v. 

M. Kitchen, et al., 

Defendants. 

No. CV 15-08228-PCT-DGC (DKD) 

ORDER 

On October 19, 2015, Plaintiff Gary Jerome Harper, who is confined in the 

Mohave County Jail, filed a pro se civil rights Complaint pursuant to 42 U.S.C. § 1983 

(Doc. 1) and an incomplete Application to Proceed In Forma Pauperis. In a November 2, 

2015 Order, the Court denied the deficient Application to Proceed with leave to refile. 

On November 12, 2015, Plaintiff filed a new Application to Proceed (Doc. 8). The Court 

will dismiss the Complaint with leave to amend. 

Also pending before the Court is Plaintiff’s October 30, 2014 “Motion for 

Extension of Time” (Doc. 5) in which Plaintiff seeks a “90 day order to attempt 

settlement negotiations before a jury trial.” Because the Court will dismiss the 

Complaint, the Court will deny the Motion as moot. 

I. Application to Proceed In Forma Pauperis and Filing Fee

 Plaintiff’s new Application to Proceed In Forma Pauperis will be granted. 28 

U.S.C. § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. 

§ 1915(b)(1). The Court will assess an initial partial filing fee of $20.00. The remainder 

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of the fee will be collected monthly in payments of 20% of the previous month’s income 

credited to Plaintiff’s trust account each time the amount in the account exceeds $10.00. 

28 U.S.C. § 1915(b)(2). The Court will enter a separate Order requiring the appropriate 

government agency to collect and forward the fees according to the statutory formula. 

II. Statutory Screening of Prisoner Complaints

 The Court is required to screen complaints brought by prisoners seeking relief 

against a governmental entity or an officer or an employee of a governmental entity. 28 

U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff 

has raised claims that are legally frivolous or malicious, that fail to state a claim upon 

which relief may be granted, or that seek monetary relief from a defendant who is 

immune from such relief. 28 U.S.C. § 1915A(b)(1)–(2). 

 A pleading must contain a “short and plain statement of the claim showing that the 

pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 

does not demand detailed factual allegations, “it demands more than an unadorned, thedefendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678 

(2009). “Threadbare recitals of the elements of a cause of action, supported by mere 

conclusory statements, do not suffice.” Id. 

 “[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a 

claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly, 

550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual 

content that allows the court to draw the reasonable inference that the defendant is liable 

for the misconduct alleged.” Id. “Determining whether a complaint states a plausible 

claim for relief [is] . . . a context-specific task that requires the reviewing court to draw 

on its judicial experience and common sense.” Id. at 679. Thus, although a plaintiff’s 

specific factual allegations may be consistent with a constitutional claim, a court must 

assess whether there are other “more likely explanations” for a defendant’s conduct. Id.

at 681. 

. . . . 

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 But as the United States Court of Appeals for the Ninth Circuit has instructed, 

courts must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 

342 (9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less 

stringent standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. 

Pardus, 551 U.S. 89, 94 (2007) (per curiam)). 

 If the Court determines that a pleading could be cured by the allegation of other 

facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal 

of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) (en banc). 

Plaintiff’s Complaint will be dismissed for failure to state a claim, but because it may 

possibly be amended to state a claim, the Court will dismiss it with leave to amend. 

III. Complaint 

 In his five-count Complaint, Plaintiff names the following Defendants: Sergeant 

M. Kitchen; Swing Shift Corporal Noba; “ADO” Vollbracht; “ADO” McCuen; Director 

Bishoff; and Mohave County Sheriff Jim McCabe. 

 In Count One, Plaintiff claims Defendant Kitchen denied him access to legal 

materials including complaint forms, paper, and additional paper. In Count Two, 

Plaintiff claims he was denied access to the courts when he was not allowed “any 

envelopes, paper, or forms to properly submit additional 1983’s to U.S. District Court.” 

In Count Three, Plaintiff alleges he was denied legal supplies “by a sergeant due to 

pending grievances there [at] the jail [and] pending lawsuits.” In Count Four, Plaintiff 

claims he was denied access to the court as well as paper and legal supplies, in violation 

of the Americans with Disabilities Act (ADA). In Count Five, Plaintiff claims he was 

“denied what [he] should have been entitled to through the ADA Title 2 integrated 

settings.” Plaintiff seeks an apology from each Defendant and money damages. 

IV. Failure to State a Claim 

 A. Legal Supplies and Access to the Court–Count One and Two 

 The right of meaningful access to the courts prohibits officials from actively 

interfering with inmates’ attempts to prepare or file legal documents. Lewis v. Casey, 

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518 U.S. 343, 350 (1996). The right of access to the courts is only a right to bring 

petitions or complaints to federal court and not a right to discover such claims or even to 

ligate them effectively once filed with a court. Id. at 354. The right “guarantees no 

particular methodology but rather the conferral of a capability–the capability of bringing 

contemplated challenges to sentences or conditions of confinement before the courts.” 

Id. at 356. 

 As a matter of standing, for an access-to-courts claim, a plaintiff must show that 

he suffered an “actual injury” with respect to contemplated litigation. Id. at 349. To 

show actual injury with respect to contemplated litigation, the plaintiff must demonstrate 

that the defendants’ conduct frustrated or impeded him from bringing to court a 

nonfrivolous claim that he wished to present. Id. at 352-53. 

 “[T]he injury requirement is not satisfied by just any type of frustrated legal 

claim.” Id. at 354. The right of access to the courts “does not guarantee inmates the 

wherewithal to transform themselves into litigating engines capable of filing everything 

from shareholder derivative actions to slip-and-fall claims.” Id. at 355. The nonfrivolous 

claim must be a direct or collateral attack on the inmate’s sentence or a challenge to the 

conditions of his confinement. Id. “Impairment of any other litigating capacity is simply 

one of the incidental (and perfectly constitutional) consequences of conviction and 

incarceration.” Id. (emphasis in original). 

Plaintiff’s claim that he was denied legal and writing supplies fails to state a claim 

for denial of access to the courts because Plaintiff has not alleged that he suffered an 

actual injury as the result of the denial of legal and writing supplies. Plaintiff does not 

allege that he was prevented from bringing to court a nonfrivolous claim attacking his 

sentence or challenging his conditions of confinement. Moreover, Plaintiff has filed 19 

new cases with this Court from September 2015 through December 2015. The Court 

finds it implausible that Plaintiff has been prevented from filing claims. 

/ / / 

/ / / 

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 B. Retaliation–Count Three 

In Count Three, Plaintiff claims an unnamed sergeant denied him legal and writing 

supplies in retaliation for filing grievances. A viable claim of First Amendment 

retaliation contains five basic elements: (1) an assertion that a state actor took some 

adverse action against an inmate (2) because of (3) that prisoner’s protected conduct, and 

that such action (4) chilled the inmate’s exercise of his First Amendment rights (or that 

the inmate suffered more than minimal harm) and (5) did not reasonably advance a 

legitimate correctional goal. Rhodes v. Robinson, 408 F.3d 559, 567-68 (9th Cir. 2005); 

see also Hines v. Gomez, 108 F.3d 265, 267 (9th Cir. 1997) (retaliation claims requires an 

inmate to show (1) that the prison official acted in retaliation for the exercise of a 

constitutionally protected right, and (2) that the action “advanced no legitimate 

penological interest”). The plaintiff has the burden of demonstrating that his exercise of 

his First Amendment rights was a substantial or motivating factor behind the defendants’ 

conduct. Mt. Healthy City School Dist. Bd. of Educ. v. Doyle, 429 U.S. 274, 287 (1977); 

Soranno’s Gasco, Inc. v. Morgan, 874 F.2d 1310, 1314 (9th Cir. 1989). 

 Although pro se pleadings are liberally construed, Haines v. Kerner, 404 U.S. 519, 

520-21 (1972), conclusory and vague allegations will not support a cause of action. Ivey 

v. Bd. of Regents of the Univ. of Alaska, 673 F.2d 266, 268 (9th Cir. 1982). Further, a 

liberal interpretation of a civil rights complaint may not supply essential elements of the 

claim that were not initially pled. Id. 

 Plaintiff’s allegations in Count Three are too vague and conclusory to state a claim 

for retaliation. Plaintiff does not describe the nature of his grievances or when they were 

filed, nor does he allege why he believes legal and writing supplies were denied because 

of the grievances. Further, Plaintiff has not identified the individual responsible for 

denying him legal and writing supplies, nor does he allege that he suffered more than 

minimal harm. Accordingly, Plaintiff has failed to state a claim in Count Three. 

/ / / 

/ / / 

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 C. ADA-Counts Four and Five 

 Under Title II of the ADA, “no qualified individual with a disability shall, by 

reason of such disability, be excluded from participation in or be denied the benefits of 

the services, programs, or activities of a public entity, or be subjected to discrimination 

by any such entity.” 42 U.S.C. § 12132. As used in this provision, a “public entity” is 

defined in part as “(A)ny State or local government; [or] (B) any department, agency, 

special purpose district, or other instrumentality of a State or States or local 

government . . . .” 42 U.S.C. § 12131. To state an ADA claim, a plaintiff must first 

demonstrate that he: 

(1) is a handicapped person; (2) that he is otherwise qualified; 

and that [prison officials=] actions either (3) excluded his 

participation in or denied him the benefits of a service, 

program, or activity; or (4) otherwise subjected him to 

discrimination on the basis of his physical handicap. 

Duffy v. Riveland, 98 F.3d 447, 455 (9th Cir. 1996). The ADA requires that the 

impairment substantially limit one or more of the individual=s major life activities. 42 

U.S.C. ' 12112(a). “Major life activities” include “functions such as caring for oneself, 

performing manual tasks, walking, seeing, speaking, breathing, learning and working.” 

29 C.F.R. ' 1630.2(i). 

 Plaintiff has not alleged that he is a handicapped person and that he is excluded 

from participation in or denied the benefits of a service, program, or activity, on the basis 

of his physical handicap. Accordingly, Plaintiff has failed to state a claim under the 

ADA in Counts Four or Five of the Complaint. 

V. Leave to Amend 

 For the foregoing reasons, Plaintiff’s Complaint will be dismissed for failure to 

state a claim upon which relief may be granted. Within 30 days, Plaintiff may submit a 

first amended complaint to cure the deficiencies outlined above. The Clerk of Court will 

mail Plaintiff a court-approved form to use for filing a first amended complaint. If 

Plaintiff fails to use the court-approved form, the Court may strike the amended 

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complaint and dismiss this action without further notice to Plaintiff. 

 Plaintiff must clearly designate on the face of the document that it is the “First 

Amended Complaint.” The first amended complaint must be retyped or rewritten in its 

entirety on the court-approved form and may not incorporate any part of the original 

Complaint by reference. Plaintiff may include only one claim per count. 

 In each count, Plaintiff must write short, plain statements telling the Court: (1) the 

constitutional right Plaintiff believes was violated; (2) the name of the Defendant who 

violated the right; (3) exactly what that Defendant did or failed to do; (4) how the action 

or inaction of that Defendant is connected to the violation of Plaintiff’s constitutional 

right; and (5) what specific injury Plaintiff suffered because of that Defendant’s conduct. 

See Rizzo v. Goode, 423 U.S. 362, 371-72, 377 (1976). 

 Plaintiff must repeat this process for each person he names as a Defendant. If 

Plaintiff fails to affirmatively link the conduct of each named Defendant with the specific 

injury suffered by Plaintiff, the allegations against that Defendant will be dismissed for 

failure to state a claim. Conclusory allegations that a Defendant or group of 

Defendants has violated a constitutional right are not acceptable and will be 

dismissed. 

 A first amended complaint supersedes the original complaint. Ferdik v. Bonzelet, 

963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner & Co., 896 

F.2d 1542, 1546 (9th Cir. 1990). After amendment, the Court will treat an original 

complaint as nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised 

in the original complaint and that was voluntarily dismissed or was dismissed without 

prejudice is waived if it is not alleged in a first amended complaint. Lacey v. Maricopa 

County, 693 F.3d 896, 928 (9th Cir. 2012) (en banc). 

VI. Warnings

A. Release

 If Plaintiff is released while this case remains pending, and the filing fee has not 

been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court 

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that he intends to pay the unpaid balance of his filing fee within 120 days of his release or 

(2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may 

result in dismissal of this action. 

B. Address Changes

 Plaintiff must file and serve a notice of a change of address in accordance with 

Rule 83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion 

for other relief with a notice of change of address. Failure to comply may result in 

dismissal of this action. 

C. Copies

 Plaintiff must submit an additional copy of every filing for use by the Court. See

LRCiv 5.4. Failure to comply may result in the filing being stricken without further 

notice to Plaintiff. 

 D. Possible “Strike”

 Because the Complaint has been dismissed for failure to state a claim, if Plaintiff 

fails to file an amended complaint correcting the deficiencies identified in this Order, the 

dismissal may count as a “strike” under the “3-strikes” provision of 28 U.S.C. § 1915(g). 

Under the 3-strikes provision, a prisoner may not bring a civil action or appeal a civil 

judgment in forma pauperis under 28 U.S.C. § 1915 “if the prisoner has, on 3 or more 

prior occasions, while incarcerated or detained in any facility, brought an action or appeal 

in a court of the United States that was dismissed on the grounds that it is frivolous, 

malicious, or fails to state a claim upon which relief may be granted, unless the prisoner 

is under imminent danger of serious physical injury.” 28 U.S.C. § 1915(g). 

E. Possible Dismissal

 If Plaintiff fails to timely comply with every provision of this Order, including 

these warnings, the Court may dismiss this action without further notice. See Ferdik, 963 

F.2d at 1260-61 (a district court may dismiss an action for failure to comply with any 

order of the Court). 

/ / / 

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IT IS ORDERED: 

(1) Plaintiff’s October 30, 2015 Motion for Extension of Time (Doc. 5) is 

denied. 

 (2) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 8) is granted. 

 (3) As required by the accompanying Order to the appropriate government 

agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing 

fee of $20.00. 

(4) The Complaint (Doc. 1) is dismissed for failure to state a claim. Plaintiff 

has 30 days from the date this Order is filed to file a first amended complaint in 

compliance with this Order. 

 (5) If Plaintiff fails to file an amended complaint within 30 days, the Clerk of 

Court must, without further notice, enter a judgment of dismissal of this action with 

prejudice that states that the dismissal may count as a “strike” under 28 U.S.C. § 1915(g). 

(6) The Clerk of Court must mail Plaintiff a court-approved form for filing a 

civil rights complaint by a prisoner. 

Dated this 2nd day of February, 2016. 

Case 3:15-cv-08228-DGC--DKD Document 10 Filed 02/02/16 Page 9 of 19
Revised 5/1/2013 1

Instructions for a Prisoner Filing a Civil Rights Complaint 

in the United States District Court for the District of Arizona

1. Who May Use This Form. The civil rights complaint form is designed to help incarcerated

persons prepare a complaint seeking relief for a violation of their federal civil rights. These

complaints typically concern, but are not limited to, conditions of confinement. This form should

not be used to challenge your conviction or sentence. If you want to challenge a state conviction

or sentence, you should file a petition under 28 U.S.C. § 2254 for a writ of habeas corpus by a

person in state custody. If you want to challenge a federal conviction or sentence, you should file

a motion under 28 U.S.C. § 2255 to vacate sentence in the federal court that entered the judgment.

2. The Form. Local Rule of Civil Procedure (LRCiv) 3.4(a) provides that complaints by

incarcerated persons must be filed on the court-approved form. The form must be typed or

neatly handwritten. The form must be completely filled in to the extent applicable. All questions

must be answered clearly and concisely in the appropriate space on the form. If needed, you may

attach additional pages, but no more than fifteen additional pages, of standard letter-sized paper.

You must identify which part of the complaint is being continued and number all pages. If you do

not fill out the form properly, you will be asked to submit additional or corrected information, which

may delay the processing of your action. You do not need to cite law. 

3. Your Signature. You must tell the truth and sign the form. If you make a false statement of a

material fact, you may be prosecuted for perjury.

4. The Filing and Administrative Fees. The total fees for this action are $400.00 ($350.00 filing fee

plus $50.00 administrative fee). If you are unable to immediately pay the fees, you may request

leave to proceed in forma pauperis. Please review the “Information for Prisoners Seeking Leave

to Proceed with a (Non-Habeas) Civil Action in Federal Court In Forma Pauperis Pursuant to 28

U.S.C. § 1915” for additional instructions.

5. Original and Judge’s Copy. You must send an original plus one copy of your complaint and of

any other documents submitted to the Court. You must send one additional copy to the Court if you

wish to have a file-stamped copy of the document returned to you. All copies must be identical to

the original. Copies may be legibly handwritten.

6. Where to File. You should file your complaint in the division where you were confined when

your rights were allegedly violated. See LRCiv 5.1(a) and 77.1(a). If you were confined in

Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. If you were confined

in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott Division. If you

were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file in the Tucson

Division. Mail the original and one copy of the complaint with the $400 filing and

administrative fees or the application to proceed in forma pauperis to:

Case 3:15-cv-08228-DGC--DKD Document 10 Filed 02/02/16 Page 10 of 19
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Phoenix & Prescott Divisions: OR Tucson Division:

U.S. District Court Clerk U.S. District Court Clerk

U.S. Courthouse, Suite 130 U.S. Courthouse, Suite 1500

401 West Washington Street, SPC 10 405 West Congress Street

Phoenix, Arizona 85003-2119 Tucson, Arizona 85701-5010

7. Change of Address. You must immediately notify the Court and the defendants in writing of any

change in your mailing address. Failure to notify the Court of any change in your mailing

address may result in the dismissal of your case.

8. Certificate of Service. You must furnish the defendants with a copy of any document you submit

to the Court (except the initial complaint and application to proceed in forma pauperis). Each

original document (except the initial complaint and application to proceed in forma pauperis) must

include a certificate of service on the last page of the document stating the date a copy of the

document was mailed to the defendants and the address to which it was mailed. See Fed. R. Civ.

P. 5(a), (d). Any document received by the Court that does not include a certificate of service may

be stricken. A certificate of service should be in the following form:

I hereby certify that a copy of the foregoing document was mailed

this (month, day, year) to:

Name: 

Address: 

 Attorney for Defendant(s)

 

(Signature)

9. Amended Complaint. If you need to change any of the information in the initial complaint, you

must file an amended complaint. The amended complaint must be written on the court-approved

civil rights complaint form. You may file one amended complaint without leave (permission) of

Court before any defendant has answered your original complaint. See Fed. R. Civ. P. 15(a). After

any defendant has filed an answer, you must file a motion for leave to amend and lodge (submit) a

proposed amended complaint. LRCiv 15.1. In addition, an amended complaint may not incorporate

by reference any part of your prior complaint. LRCiv 15.1(a)(2). Any allegations or defendants

not included in the amended complaint are considered dismissed. All amended complaints are

subject to screening under the Prison Litigation Reform Act; screening your amendment will take

additional processing time.

10. Exhibits. You should not submit exhibits with the complaint or amended complaint. Instead,

the relevant information should be paraphrased. You should keep the exhibits to use to support or

oppose a motion to dismiss, a motion for summary judgment, or at trial.

11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff of

any judge. The only appropriate way to communicate with the Court is by filing a written pleading

or motion.

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3

12. Completing the Civil Rights Complaint Form.

HEADING:

1. Your Name. Print your name, prison or inmate number, and institutional mailing address

on the lines provided.

2. Defendants. If there are four or fewer defendants, print the name of each. If you name

more than four defendants, print the name of the first defendant on the first line, write the

words “and others” on the second line, and attach an additional page listing the names of all

of the defendants. Insert the additional page after page 1 and number it “1-A” at the bottom.

3. Jury Demand. If you want a jury trial, you must write “JURY TRIAL DEMANDED” in

the space below “CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do so may

result in the loss of the right to a jury trial. A jury trial is not available if you are seeking

only injunctive relief.

Part A. JURISDICTION:

1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. § 1983

for state, county, or city defendants; “Bivens v. Six Unknown Federal Narcotics Agents” for

federal defendants; or “other.” If you mark “other,” identify the source of that authority. 

2. Location. Identify the institution and city where the alleged violation of your rights

occurred. 

3. Defendants. Print all of the requested information about each of the defendants in the

spaces provided. If you are naming more than four defendants, you must provide the

necessary information about each additional defendant on separate pages labeled “2-A,” “2-

B,” etc., at the bottom. Insert the additional page(s) immediately behind page 2.

Part B. PREVIOUS LAWSUITS:

You must identify any other lawsuit you have filed in either state or federal court while you

were a prisoner. Print all of the requested information about each lawsuit in the spaces provided.

If you have filed more than three lawsuits, you must provide the necessary information about each

additional lawsuit on a separate page. Label the page(s) as “2-A,” “2-B,” etc., at the bottom of the

page and insert the additional page(s) immediately behind page 2.

Part C. CAUSE OF ACTION:

You must identify what rights each defendant violated. The form provides space to allege

three separate counts (one violation per count). If you are alleging more than three counts, you

must provide the necessary information about each additional count on a separate page. Number

the additional pages “5-A,” “5-B,” etc., and insert them immediately behind page 5. Remember that

you are limited to a total of fifteen additional pages.

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1. Counts. You must identify which civil right was violated. You may allege the violation

of only one civil right per count.

2. Issue Involved. Check the box that most closely identifies the issue involved in your

claim. You may check only one box per count. If you check the box marked “Other,” you

must identify the specific issue involved.

3. Supporting Facts. After you have identified which civil right was violated, you must state

the supporting facts. Be as specific as possible. You must state what each individual

defendant did to violate your rights. If there is more than one defendant, you must identify

which defendant did what act. You also should state the date(s) on which the act(s)

occurred, if possible.

4. Injury. State precisely how you were injured by the alleged violation of your rights. 

5. Administrative Remedies. You must exhaust any available administrative remedies

before you file a civil rights complaint. See 42 U.S.C. § 1997e. Consequently, you should

disclose whether you have exhausted the inmate grievance procedures or administrative

appeals for each count in your complaint. If the grievance procedures were not available for

any of your counts, fully explain why on the lines provided.

Part D. REQUEST FOR RELIEF:

Print the relief you are seeking in the space provided. 

SIGNATURE:

You must sign your name and print the date you signed the complaint. Failure to sign the

complaint will delay the processing of your action. Unless you are an attorney, you may not bring

an action on behalf of anyone but yourself.

FINAL NOTE

You should follow these instructions carefully. Failure to do so may result in your complaint

being stricken or dismissed. All questions must be answered concisely in the proper space on the

form. If you need more space, you may attach no more than fifteen additional pages. But the form

must be completely filled in to the extent applicable. If you attach additional pages, be sure to

identify which section of the complaint is being continued and number the pages.

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Revised 5/1/2013 1 550/555

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

(Failure to notify the Court of your change of address may result in dismissal of this action.)

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

)

 , )

(Full Name of Plaintiff) Plaintiff, )

)

 vs. ) CASE NO. 

) (To be supplied by the Clerk)

(1) , )

(Full Name of Defendant) )

(2) , )

) CIVIL RIGHTS COMPLAINT

(3) ,) BY A PRISONER

)

(4) , ) G Original Complaint

Defendant(s). ) G First Amended Complaint

G Check if there are additional Defendants and attach page 1-A listing them. ) G Second Amended Complaint

A. JURISDICTION

1. This Court has jurisdiction over this action pursuant to:

G 28 U.S.C. § 1343(a); 42 U.S.C. § 1983

G 28 U.S.C. § 1331; Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971).

G Other: .

2. Institution/city where violation occurred: .

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B. DEFENDANTS

1. Name of first Defendant: . The first Defendant is employed as:

at .

(Position and Title) (Institution)

2. Name of second Defendant: . The second Defendant is employed as:

at .

(Position and Title) (Institution)

3. Name of third Defendant: . The third Defendant is employed as:

at .

(Position and Title) (Institution)

4. Name of fourth Defendant: . The fourth Defendant is employed as:

at .

(Position and Title) (Institution)

If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page.

C. PREVIOUS LAWSUITS

1. Have you filed any other lawsuits while you were a prisoner? G Yes G No

2. If yes, how many lawsuits have you filed? . Describe the previous lawsuits:

a. First prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

b. Second prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

c. Third prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

If you filed more than three lawsuits, answer the questions listed above for each additional lawsuit on a separate page.

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D. CAUSE OF ACTION

COUNT I

1. State the constitutional or other federal civil right that was violated: 

.

2. Count I. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count I. Describe exactly what each

Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal

authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies:

a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your

institution? G Yes G No

b. Did you submit a request for administrative relief on Count I? G Yes G No

c. Did you appeal your request for relief on Count I to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you

did not. 

.

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COUNT II

1. State the constitutional or other federal civil right that was violated: 

.

2. Count II. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count II. Describe exactly what each

Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal

authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies.

a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your

institution? G Yes G No

b. Did you submit a request for administrative relief on Count II? G Yes G No

c. Did you appeal your request for relief on Count II to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you

did not. 

.

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COUNT III

1. State the constitutional or other federal civil right that was violated: 

.

2. Count III. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count III. Describe exactly what each

Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal

authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies.

a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your

institution? G Yes G No

b. Did you submit a request for administrative relief on Count III? G Yes G No

c. Did you appeal your request for relief on Count III to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you

did not. 

.

If you assert more than three Counts, answer the questions listed above for each additional Count on a separate page.

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E. REQUEST FOR RELIEF

State the relief you are seeking:

.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on 

DATE SIGNATURE OF PLAINTIFF

(Name and title of paralegal, legal assistant, or

other person who helped prepare this complaint)

(Signature of attorney, if any)

(Attorney’s address & telephone number)

ADDITIONAL PAGES

All questions must be answered concisely in the proper space on the form. If you need more space, you may attach

no more than fifteen additional pages. But the form must be completely filled in to the extent applicable. If you

attach additional pages, be sure to identify which section of the complaint is being continued and number all pages.

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