Source: http://themoreaus.tripod.com/id5.html
Timestamp: 2019-08-23 17:43:51
Document Index: 450087131

Matched Legal Cases: ['§ 1983', '§ 1331', '§ 1343', '§ 1915', '§ 1746', '§ 1621']

Full Name/Prisoner Number
FOR THE ______________DISTRICT OF LOUISIANA
(Full name and prisoner number.) ) (To be supplied by the Court)
) PRISONER CIVIL RIGHTS
_______________________________________ ) COMPLAINT
(Full name(s). Do not use et. al.) )
1. ______________________________________ is a citizen of ______________________
(Plaintiff) (State)
presently residing at ___________________________________________________________.
2. Defendant__________________________________ is a citizen of _________________
(Name of first defendant) (State)
whose address is _______________________________________________________________,
and who is employed as _________________________________________________________.
(Title and place of employment)
At the time the claim(s) alleged in this complaint arose, was this defendant acting under color
Prisoner Civil Rights Complaints (Rev. 11-02) 16
of state law? ___Yes ____No. If your answer if "Yes", briefly explain: __________________
3. Defendant _________________________________ is a citizen of _________________
(Name of second defendant) (State)
At the time the claim(s) alleged in this complaint arose, was this defendant acting under color of state law?
___Yes ____No. If your answer is "Yes", briefly explain: ________________
NOTE: If more space is needed to furnish the above information for additional defendants, continue on a blank sheet which you should label
"APPENDIX A. PARTIES".
Be sure to include the same information for each defendant including their complete address and title.
1. Jurisdiction is asserted pursuant to (CHECK ONE)
____ 42 U.S.C. § 1983 (applies to state prisoners)
____ Bivens v. Six Unknown Named Agents of Fed. Bureau of Narcotics, 403
U.S. 388 (1971) and 28 U.S.C. § 1331 (applies to federal prisoners)
Prisoner Civil Rights Complaints (Rev. 11-02) 17
2. Jurisdiction also is invoked pursuant to 28 U.S.C. § 1343(a)(3). (If you wish to assert jurisdiction under different or additional statutes, you may list them below.)
1. I allege that the following of my constitutional rights, privileges, or immunities have been violated :
If more space is needed to explain any allegation or to list additional supporting facts, continue on a blank
sheet which you should label "APPENDIX D. CAUSE OF ACTION".
2. Supporting Facts: (Include all facts you consider important, including names of persons involved, places, and dates. Describe exactly how each defendant is involved.
State the facts clearly in your own words without citing legal authority or argument.
Prisoner Civil Rights Complaints (Rev. 11-02) 18
D. PREVIOUS LAWSUITS
1. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action or otherwise relating to the conditions of your imprisonment? Yes ___ No ___.
If your answer is "Yes", describe each lawsuit. (If there is more than one lawsuit, described the additional lawsuits using this same format on a blank sheet which you should label "APPENDIX E. PREVIOUS LAWSUITS".)
Prisoner Civil Rights Complaints (Rev. 11-02) 19
Plaintiff(s): ______________________________________________________
Defendant(s) ______________________________________________________
b. Name and location of court and docket (case) number: _____________________
c. Disposition of lawsuit. (For example, was the case dismissed? Was it appealed?
It is still pending?) _________________________________________________
d. Issues raised: ______________________________________________________
e. Approximate date of filing lawsuit: ____________________________________
f. Approximate date of disposition: ______________________________________
E. EXHAUSTION OF PRISON OR JAIL GRIEVANCE SYSTEM
1. I have exhausted the grievance system within the jail or prison in which I am incarcerated. ____Yes ____No.
If your answer is "Yes", briefly explain the steps taken to exhaust each claim you are bringing against each Defendant. It is advisable to attach proof of exhaustion. If your answer is "No", briefly explain why the grievance system or other administrative remedies were not exhausted.
Prisoner Civil Rights Complaints (Rev. 11-02) 20
F. PREVIOUSLY DISMISSED ACTIONS OR APPEALS
1. If you are proceeding under 28 U.S.C. § 1915, please list each civil action or appeal you have brought in a court of the United States, while you were incarcerated or detained in any facility, that was dismissed as frivolous, malicious, or for failure to state a claim upon which relief may be granted.
Please describe each civil action or appeal. If there is more than one civil action or appeal, describe the additional civil actions or appeals using this same format on a blank sheet which you should label
"APPENDIX F. PREVIOUSLY DISMISSED ACTIONS OR APPEALS".
Defendant(s): ______________________________________________________
c. Grounds for dismissal: ( ) frivolous ( ) malicious ( ) failure to state a claim upon which relief may be granted.
d. Approximate date of filing lawsuit: ____________________________________
e. Approximate date of disposition: ______________________________________
G. IMMINENT HARM
1. Are you in imminent danger of serious physical injury? _____Yes ____No. If your answer is "Yes", please describe the facts in detail below without citing legal authority or argument.
Prisoner Civil Rights Complaints (Rev. 11-02) 21
I. Request for Appointment of Attorney
I do ____ do not _____ request that an attorney be appointed to represent me in this matter. I believe
that I am in need of an attorney for these particular reasons which make it difficult for me to pursue this
matter without an attorney: _________________________________________________________
Prisoner Civil Rights Complaints (Rev. 11-02) 22
Prisoner Original Signature
The undersigned declares under penalty of perjury that he/she is the plaintiff in the above action, that he/she has read the above complaint and that the information contained in the complaint is true and
correct. 28 U.S.C. § 1746; 18 U.S.C. § 1621.
Executed at ___________________________________ on ___________________________
Prisoner's Original Signature