Domingo v. Thomas et al

Filing 7

ORDER - The 1 Complaint 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. 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). Signed by Judge David G Campbell on 1/2/13. (LAD)

1
2

SC

WO

3
4
5
6

IN THE UNITED STATES DISTRICT COURT

7

FOR THE DISTRICT OF ARIZONA

8
Desmond Domingo,
9
Plaintiff,
10
vs.
11
Todd Thomas, et al.,
12
Defendants.
13

)
)
)
)
)
)
)
)
)
)

No. CV 12-1775-PHX-DGC (SPL)
ORDER

14

Plaintiff Desmond Domingo, a Hawaiian inmate who is now confined in the Waiawa

15

Correctional Facility in Pearl City, Hawaii, filed a pro se civil rights Complaint pursuant to

16

42 U.S.C. § 1983. He subsequently paid the $350.00 filing fee. The Court will dismiss the

17

Complaint with leave to amend.

18

I.

Statutory Screening of Prisoner Complaints

19

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

20

a governmental entity or an officer or an employee of a governmental entity. 28 U.S.C.

21

§ 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff has raised

22

claims that are legally frivolous or malicious, that fail to state a claim upon which relief may

23

be granted, or that seek monetary relief from a defendant who is immune from such relief.

24

28 U.S.C. § 1915A(b)(1), (2).

25
26

pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 does not

27

demand detailed factual allegations, “it demands more than an unadorned, the-defendant-

28
JDDL-K

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

unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 129 S. Ct. 1937, 1949 (2009).

1

“Threadbare recitals of the elements of a cause of action, supported by mere conclusory

2

statements, do not suffice.” Id.

3

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

4

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

5

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

6

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

7

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

8

relief [is] . . . a context-specific task that requires the reviewing court to draw on its judicial

9

experience and common sense.” Id. at 1950. Thus, although a plaintiff’s specific factual

10

allegations may be consistent with a constitutional claim, a court must assess whether there

11

are other “more likely explanations” for a defendant’s conduct. Id. at 1951.

12

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

13

must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 342 (9th

14

Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less stringent standards

15

than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. Pardus, 551 U.S. 89,

16

94 (2007) (per curiam)).

17

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

18

a pro se litigant is entitled to an opportunity to amend a complaint before dismissal of the

19

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

20

should not, however, advise the litigant how to cure the defects. This type of advice “would

21

undermine district judges’ role as impartial decisionmakers.” Pliler v. Ford, 542 U.S. 225,

22

231 (2004); see also Lopez, 203 F.3d at 1131 n.13 (declining to decide whether the court was

23

required to inform a litigant of deficiencies). The Court will dismiss Plaintiff’s Complaint

24

for failure to state a claim, but because the Complaint may possibly be saved by amendment,

25

the Court will dismiss the Complaint with leave to amend.

26

II.

Complaint

27
28
JDDL-K

Plaintiff alleges one count for threat to safety regarding events that occurred while he
was incarcerated in the Saguaro Correctional Center (SCC), a correctional facility operated
-2-

1

by Corrections Corporation of America in Eloy, Arizona. Plaintiff sues Corrections

2

Corporation of America (CCA) and the following current or former employees of SCC:

3

Warden Todd Thomas; Assistant Warden Jody Bradley; and Recreational Coordinator John

4

Rael. Plaintiff seeks compensatory relief.

5

Plaintiff alleges the following facts in his Complaint: on April 4, 2012, Plaintiff went

6

outdoor recreation to use the weight-lifting equipment. The equipment had recently been

7

inspected and tested and new cables put on the equipment. While Plaintiff was pulling the

8

bar down, a loose screw caused the cable to pop free from the weights, which resulted in the

9

bar hitting Plaintiff’s head. Plaintiff was taken to the prison medical unit where photographs

10

of his head injury were taken and staples were used to close wound. Plaintiff was given

11

Ibuprofen for three weeks after the injury for pain. Plaintiff contends that the weight

12

equipment was faulty and caused a three inch gash in his head and left a scar. He further

13

contends that if each of the Defendants provided proper maintenance and inspection of the

14

equipment, the accident would not have occurred.

15

III.

Failure to State a Claim

16

To state a claim under § 1983, a plaintiff must allege facts supporting that (1) the

17

conduct about which he complains was committed by a person acting under the color of state

18

law and (2) the conduct deprived him of a federal constitutional or statutory right. Wood v.

19

Outlander, 879 F.2d 583, 587 (9th Cir. 1989). Negligence is not sufficient to state a claim

20

under § 1983. Daniels v. Williams, 474 U.S. 327, 330-31 (1986). In addition, a plaintiff

21

must allege that he suffered a specific injury as a result of the conduct of a particular

22

defendant and he must allege an affirmative link between the injury and the conduct of that

23

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

24
25

support that he was incarcerated under conditions posing a substantial risk of harm and that

26

prison officials were “deliberately indifferent” to those risks. Farmer v. Brennan, 511 U.S.

27

825, 832-33 (1994). To adequately allege deliberate indifference, a plaintiff must allege facts

28
JDDL-K

To state a claim under § 1983 for threat to safety, an inmate must allege facts to

to support that a defendant knew of, but disregarded, an excessive risk to inmate safety. Id.
-3-

1

at 837. That is, “the official must both [have been] aware of facts from which the inference

2

could be drawn that a substantial risk of serious harm exist[ed], and he must also [have]

3

draw[n] the inference.” Id.

4

A.

CCA

5

Plaintiff sues CCA, a private corporation for violations of federal and state law rights.

6

Claims under § 1983 may be directed at “bodies politic and corporate.” Monell v. New York

7

City Dep’t of Soc. Servs., 436 U.S. 686, 688-89 (1978). Under the Civil Rights Act of 1871,

8

Congress intended municipal corporations and other local government units to be included

9

among those persons to whom § 1983 applies. Id. at 2035. That proposition has been

10

extended to corporations that act under color of state law. See Sable Commc’s of Cal. Inc.

11

v. Pacific Tel. & Tel Co., 890 F.2d 184, 189 (9th Cir. 1989) (willful joint participation of

12

private corporation in joint activity with state or its agent taken under color of state law).

13
14

the private actor performs a public function, (2) the private actor engages in joint activity

15

with a state actor, (3) a private actor is subject to governmental compulsion or coercion, or

16

(4) there is a governmental nexus with the private actor. Kirtley v. Rainey, 326 F.3d 1088,

17

1093 (9th Cir. 2003). Under the public function test, “the function [performed by the private

18

actor] must traditionally be the exclusive prerogative of the state.” Parks Sch. of Bus., Inc.

19

v. Symington, 51 F.3d 1480, 1486 (9th Cir. 1995); see Kirtley, 326 F.3d at 1093; Lee v. Katz,

20

276 F.3d 550, 554-555 (9th Cir. 2002). A privately owned corporation that operates prisons

21

pursuant to a contract with a state performs a public function that is traditionally the

22

exclusive prerogative of the state. But, to state a claim under § 1983 against a private entity

23

performing a traditional public function, a plaintiff must allege facts to support that his

24

constitutional rights were violated as a result of a policy, decision, or custom promulgated

25

or endorsed by the private entity. See Buckner v. Toro, 116 F.3d 450, 452 (11th Cir. 1997);

26

Street v. Corrections Corp. of Am., 102 F.3d 810, 814 (6th Cir. 1996); Wall v. Dion, 257 F.

27

Supp.2d 316, 319 (D. Me 2003); see also Austin v. Paramount Parks, Inc., 195 F.3d 715, 727

28
JDDL-K

There are four ways to find state action by a private entity for purposes of § 1983: (1)

(4th Cir. 1999); Rojas v. Alexander’s Dep’t Store, Inc., 924 F.2d 406, 408 (2d Cir. 1990);
-4-

1

Lux by Lux v. Hansen, 886 F.2d 1064, 1067 (8th Cir. 1989).

2

CCA performs the traditional public function of operating a prison, but Plaintiff fails

3

to allege facts to show that CCA promulgated or endorsed a policy or custom that resulted

4

in a violation of Plaintiff’s constitutional rights. Further, there is no respondeat superior

5

liability under § 1983, so a defendant’s position as the employer of someone who allegedly

6

violated a plaintiff’s constitutional rights does not make it liable. Monell, 436 U.S. at 691;

7

Taylor v. List, 880 F.2d 1040, 1045 (9th Cir. 1989). Because Plaintiff fails to allege any

8

facts against CCA, it will be dismissed.

9
10
11

B.

Individual Defendants

Plaintiff also sues Defendants Thomas, Bradley, and Rael. While these individuals
may be sued, Plaintiff fails to state a claim against any of them.

12

To state a constitutional claim against a defendant, “[a] plaintiff must allege facts, not

13

simply conclusions, that show that an individual was personally involved in the deprivation

14

of his civil rights.” Barren v. Harrington, 152 F.3d 1193, 1194 (9th Cir. 1998). For an

15

individual to be liable in his official capacity, a plaintiff must allege that the official acted

16

as a result of a policy, practice, or custom. See Cortez v. County of Los Angeles, 294 F.3d

17

1186, 1188 (9th Cir. 2001). Further, there is no respondeat superior liability under § 1983,

18

so a defendant’s position as the supervisor of someone who allegedly violated a plaintiff’s

19

constitutional rights does not make him liable. Monell, 436 U.S. at 691; Taylor, 880 F.2d

20

at 1045. A supervisor in his individual capacity, “is only liable for constitutional violations

21

of his subordinates if the supervisor participated in or directed the violations, or knew of the

22

violations and failed to act to prevent them.” Taylor, 880 F.2d at 1045.

23
24

of the weight-lifting equipment and to have it properly inspected. These allegations at most

25

allege that the individual Defendants were negligent. As noted above, negligence is not

26

sufficient to state a claim under § 1983. Instead, Plaintiff must allege facts to support that

27

each of the Defendants knew, or should have known, that the weight-lifting equipment posed

28
JDDL-K

Plaintiff alleges that the individual Defendants failed to provide proper maintenance

a substantial risk to Plaintiff’s safety, but nevertheless failed to prevent its use by Plaintiff.
-5-

1

Plaintiff has not alleged such facts. Accordingly, he also fails to state a claim against any of

2

the individual Defendants.

3

IV.

Leave to Amend

4

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

5

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

6

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

7

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

8

to use the court-approved form, the Court may strike the amended complaint and dismiss this

9

action without further notice to Plaintiff.

10

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

11

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

12

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

13

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

14

A first amended complaint supersedes the original complaint. Ferdik v. Bonzelet, 963

15

F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner & Co., 896 F.2d 1542,

16

1546 (9th Cir. 1990). After amendment, the Court will treat an original complaint as

17

nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised in the original

18

complaint is waived if it is not raised in a first amended complaint. King v. Atiyeh, 814 F.2d

19

565, 567 (9th Cir. 1987).

20

V.

Warnings

21

A.

Address Changes

22

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

23

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

24

relief with a notice of change of address. Failure to comply may result in dismissal of this

25

action.

26
27

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

28
JDDL-K

B.

Copies

LRCiv 5.4. Failure to comply may result in the filing being stricken without further notice
-6-

1

to Plaintiff.

2

C.

3

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

4

warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d at

5

1260-61 (a district court may dismiss an action for failure to comply with any order of the

6

Court).

7

IT IS ORDERED:

8
9
10
11

(1)

Possible Dismissal

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.
(2)

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

12

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

13

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

14
15
16

(3)

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 January, 2013.

17
18
19
20
21
22
23
24
25
26
27
28
JDDL-K

-7-

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 Fee. The filing fee for this action is $350.00. If you are unable to immediately
pay the filing fee, 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 $350 filing
fee or the application to proceed in forma pauperis to:

Revised 3/9/07

1

Phoenix & Prescott Divisions:
OR
U.S. District Court Clerk
U.S. Courthouse, Suite 130
401 West Washington Street, SPC 10
Phoenix, Arizona 85003-2119

Tucson Division:
U.S. District Court Clerk
U.S. Courthouse, Suite 1500
405 West Congress Street
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 courtapproved 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.
2

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 “1A” 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,” “2B,” 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.
3

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.

4

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.

(1)
(Full Name of Defendant)

(2)
(3)
(4)
Defendant(s).

G

Check if there are additional Defendants and attach page 1-A listing them.

)
, )
)
)
) CASE NO.
)
(To be supplied by the Clerk)
, )
)
, )
CIVIL RIGHTS COMPLAINT
)
, )
BY A PRISONER
)
, )
G Original Complaint
G First Amended Complaint
)
)
G Second Amended Complaint

A. JURISDICTION
1.

2.

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:

.

Institution/city where violation occurred:

.

Revised 3/9/07

1

550/555

B. DEFENDANTS
1.

Name of first Defendant:
at

. The first Defendant is employed as:
.

(Position and Title)

2.

(Institution)

Name of second Defendant:
at

. The second Defendant is employed as:
.

(Position and Title)

3.

(Institution)

Name of third Defendant:
at

. The third Defendant is employed as:
.

(Position and Title)

4.

(Institution)

Name of fourth Defendant:
at

. The fourth Defendant is employed as:
.

(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?

2.

If yes, how many lawsuits have you filed?

G Yes

G No

. 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:
v.
1. Parties:
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.

2

D. CAUSE OF ACTION

1.

COUNT I
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
G Yes G No
at your institution?
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.
.
3

1.

COUNT II
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.
.
4

1.

COUNT III
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
G Yes G No
at your institution?
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.

5

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.

6