Donaldson v. Phoenix Police Department

Filing 10

ORDER granting 6 Plaintiff's Motion for Leave to Proceed in forma pauperis. The First Amended Complaint (Doc. 9) is dismissed for failure to state a claim. Plaintiff has 30 days from the date this Order is filed to file a second amended compla int in compliance with this Order. If Plaintiff fails to file a second 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). The Clerk of Court must mail Plaintiff a court-approved form for filing a civil rights complaint by a prisoner.Signed by Judge David G Campbell on 11/2/12.(TLJ)

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SVK

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IN THE UNITED STATES DISTRICT COURT

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FOR THE DISTRICT OF ARIZONA

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DeJuan Donaldson,

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Plaintiff,

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vs.

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The Phoenix Police Department, et al.,
Defendants.

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No. CV 12-1816-PHX-DGC (JFM)
ORDER

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Plaintiff DeJuan Donaldson, who is confined in the Maricopa County Fourth Avenue

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Jail, filed a pro se civil rights Complaint pursuant to 42 U.S.C. § 1983, which was received

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by the Clerk of Court on August 27, 20121 and an Application to Proceed In Forma

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Pauperis. In a previous Order, the Court denied the Application to Proceed and gave

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Plaintiff 30 days to file a completed Application to Proceed. (Doc. 4.)

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On September 13, 2012, Plaintiff filed a second Application to Proceed (Doc. 6), and

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on October 10, 2012, Plaintiff’s new Complaint was received by the Court; it is undated and

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unsigned. (Doc. 9.) The Court will construe it as a First Amended Complaint and dismiss

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it with leave to amend.

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I.

Application to Proceed In Forma Pauperis and Filing Fee

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Plaintiff’s Application to Proceed In Forma Pauperis will be granted. 28 U.S.C.

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§ 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. § 1915(b)(1).

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JDDL-K

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The original Complaint is not dated or signed.

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The Court will assess an initial partial filing fee of $23.38. The remainder of the fee will be

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collected monthly in payments of 20% of the previous month’s income each time the amount

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in the account exceeds $10.00. 28 U.S.C. § 1915(b)(2). The Court will enter a separate

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Order requiring the appropriate government agency to collect and forward the fees according

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to the statutory formula.

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II.

Statutory Screening of Prisoner Complaints

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

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

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

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

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

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28 U.S.C. § 1915A(b)(1), (2).

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

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

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factual allegations, “it demands more than an unadorned, the-defendant-unlawfully-harmed-

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me accusation.” Ashcroft v. Iqbal, 129 S. Ct. 1937, 1949 (2009). “Threadbare recitals of the

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elements of a cause of action, supported by mere conclusory statements, do not suffice.” Id.

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

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

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

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

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

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

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

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

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

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

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

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94 (2007) (per curiam)).

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

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

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

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

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

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

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

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Amended Complaint for failure to state a claim, but because the First Amended Complaint

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may possibly be saved by amendment, will grant leave to amend.

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III.

First Amended Complaint

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In his First Amended Complaint, which Plaintiff labels “Copy of Original

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Complaint,”2 Plaintiff sues the Phoenix Police Department. Plaintiff alleges that on May 11,

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2011, while he was being arrested and detained, he was aggressively and forcefully thrown

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to the ground, which resulted in physical injury. He asserts that since that time he has been

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put on national television and profiled as a serial rapist, which is slander, and that during the

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police investigation, he was “racially profiled to fit the description of an alleged rape

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suspect.” (Doc. 9 at 1.) He claims that the alleged victim’s statements document that

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Plaintiff does not fit the description of the alleged suspect and that officers who had Plaintiff

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under surveillance stated that Plaintiff did not fit the description. (Id. at 3.)

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IV.

Failure to State a Claim

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A.

Excessive Force

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The Fourth Amendment does not prohibit the use of reasonable force; the right to

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make an arrest carries with it the inherent right to use some force. Hicks v. City of Portland,

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Although the newly filed Complaint is substantially the same as the original
Complaint, it is not a copy.
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2006 WL 3311552, at *9 (D. Or. Nov. 8, 2006) (citing Graham v. Connor, 490 U.S. 386, 396

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(1989)). Plaintiff’s allegation that police officers used force during Plaintiff’s arrest is not

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sufficient to state a claim. Plaintiff does not allege that the force was unreasonable or

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unnecessary and therefore fails to state a claim.

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In addition, although local government bodies are persons under § 1983 and may be

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sued for constitutional injuries, liability may be imposed on the entity only if a plaintiff

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establishes that his injuries were inflicted pursuant to an official policy or custom.

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Thompson v. City of Los Angeles, 885 F.2d 1439, 1443 (9th Cir. 1989) (citations omitted).

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In this case, Plaintiff has not alleged that his injuries resulted from a custom or policy

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of the Phoenix Police Department. Accordingly, Defendant Phoenix Police Department must

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be dismissed.

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B.

Slander and Libel

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The allegations of slander and libel do not state a federal claim. Section 1983 does

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not provide a cause of action for violations of state law or state constitutional rights. Ybarra

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v. Bastian, 647 F.2d 891, 892 (9th Cir. 1981).

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Merely asserting “racial profiling” during a police investigation does not state a claim.

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Plaintiff may be trying to state a claim for false arrest or malicious prosecution. To maintain

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an action for false arrest, a plaintiff must plead facts to show that a defendant procured an

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arrest that was without probable cause. Lacey v. Maricopa County, 693 F. 3d 896, 918 (9th

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Cir. 2012). As to malicious prosecution, “[m]alicious prosecution, by itself, does not

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constitute a due process violation; to prevail [a plaintiff] must show that the defendants

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prosecuted [him] with malice and without probable cause, and that they did so for the

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purpose of denying [him] equal protection or another specific constitutional right.” Freeman

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v. City of Santa Ana, 68 F.3d 1180, 1189 (9th Cir. 1995); Awabdy v. City of Adelanto 368

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F.3d 1062, 1066 (9th Cir. 2004). A plaintiff asserting a malicious prosecution action must

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also allege that the prior criminal proceedings terminated in his favor. Id., at 1068; Guerrero

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C.

Racial Profiling

v. Gates, 442 F.3d 697, 704 (9th Cir. 2006).
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V.

Leave to Amend

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For the foregoing reasons, Plaintiff’s First Amended Complaint will be dismissed for

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

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submit a second amended complaint to cure the deficiencies outlined above. The Clerk of

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Court will mail Plaintiff a court-approved form to use for filing a second amended complaint.

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

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complaint and dismiss this action without further notice to Plaintiff. If Plaintiff fails to use

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the court-approved form, the Court may strike the second amended complaint and

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dismiss this action without further notice to Plaintiff. In addition, Plaintiff must sign

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his Second Amended Complaint.

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

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

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

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Complaint or First Amended Complaint by reference. Plaintiff may include only one claim

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per count.

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A second amended complaint supersedes the original Complaint and First Amended

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Complaint. Ferdik v. Bonzelet, 963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v.

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Richard Feiner & Co., 896 F.2d 1542, 1546 (9th Cir. 1990). After amendment, the Court will

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treat the original Complaint and First Amended Complaint as nonexistent. Ferdik, 963 F.2d

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at 1262. Any cause of action that was raised in the original Complaint or First Amended

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complaint is waived if it is not raised in a second amended complaint. King v. Atiyeh, 814

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F.2d 565, 567 (9th Cir. 1987).

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VI.

Warnings

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Plaintiff must pay the unpaid balance of the filing fee within 120 days of his release.

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Also, within 30 days of his release, he must either (1) notify the Court that he intends to pay

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the balance or (2) show good cause, in writing, why he cannot. Failure to comply may result

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A.

Release

in dismissal of this action.
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B.

Address Changes

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

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

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

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action.

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C.

Copies

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

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

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to Plaintiff.

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D.

Possible “Strike”

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Because the First Amended Complaint has been dismissed for failure to state a claim,

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if Plaintiff fails to file a second amended complaint correcting the deficiencies identified in

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this Order, the dismissal may count as a “strike” under the “3-strikes” provision of 28 U.S.C.

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§ 1915(g). Under the 3-strikes provision, a prisoner may not bring a civil action or appeal

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

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

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

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

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

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E.

Possible Dismissal

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

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

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

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Court).

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IT IS ORDERED:

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(1)

Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 6) is granted.

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(2)

As required by the accompanying Order to the appropriate government agency,

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Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing fee of $ 23.38.
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(3)

The First Amended Complaint (Doc. 9) is dismissed for failure to state a claim.

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

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compliance with this Order.

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(4)

If Plaintiff fails to file a second amended complaint within 30 days, the Clerk

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

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

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(5)

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 November, 2012.

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INFORMATION AND INSTRUCTIONS FOR A
PRISONER FILING CIVIL RIGHTS COMPLAINT
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
I. General Information About the Civil Rights Complaint Form:
A. The Form. The civil rights complaint form is designed to help prisoners prepare a complaint
seeking relief for a violation of their federal civil rights. Local Rule of Civil Procedure 3.4(a)
requires that prisoner civil rights complaints be filed on the court-approved form. Your
complaint must be typewritten or legibly handwritten. All information must be clearly and
concisely written, only in the space provided on the form. If needed, you may attach no more
than fifteen additional pages of standard letter size paper to continue any part of the complaint.
You must identify which part of the complaint is being continued and number all pages.
B. Your Signature. You must sign the complaint. Your signature constitutes a certificate that:
1) you have read the complaint; 2) to the best of your knowledge, information and belief formed
after reasonable inquiry it is well grounded in fact and law; and 3) it is not being filed for any
improper purpose. Please review Rule 11 of the Federal Rules of Civil Procedure. Rule 11
provides for the imposition of sanctions if the complaint is signed in violation of the Rule.
C. The Filing Fee. You must pay the $350.00 filing fee. If you are unable to pay the filing fee
when the complaint is filed, 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 more information.
D. Court Divisions. If you resided in Maricopa, Pinal, Yuma, La Paz, or Gila county when
your rights were allegedly violated, you should file your complaint in the Phoenix Division of
the court. If you resided in Apache, Navajo, Coconino, Mohave, or Yavapai county when your
rights were allegedly violated, you should file your complaint in the Prescott Division of the
court. If you resided in Pima, Cochise, Santa Cruz, Graham, or Greenlee county when your
rights were allegedly violated, you should file your complaint in the Tucson Division of the
court. See LRCiv 5.1(a) and 77.1(a).
You should mail THE ORIGINAL AND ONE COPY of your complaint with the
$350.00 filing fee or the application to proceed in forma pauperis to:
Phoenix & Prescott Divisions:

OR

U.S. District Court Clerk
U.S. Courthouse, Suite 321
401 West Washington Street, SPC 10
Phoenix, Arizona 85003-2119

Revised 4/9/06

Tucson Division:
U.S. District Court Clerk
U.S. Courthouse, Suite 1500
405 West Congress Street
Tucson, Arizona 85701-5010

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E. Certificate of Service on Defendants. You must furnish the opposing party or their attorney
with a copy of any document you submit to the court (except the initial complaint and
application to proceed in forma pauperis). Pursuant to Rules 5(a) and (d) of the Federal Rules
of Civil Procedure, each original document (except the initial complaint and application for
leave 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 opposing party or their
attorney and the address to which it was mailed. Any document received by the court which
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
day of (month) , (year) , to:
Name:
Address:
Attorney for Defendant(s)/Respondent(s)

(Signature)
F. Original and Judge's Copy. You must furnish an original and one copy of any document
submitted to the court. You must furnish one additional copy to the clerk if you wish to have
a file-stamped copy of the document returned to you. All copies must be identical to the
original.
G. Exhibits. You should not submit exhibits with the complaint. Instead, the relevant
information should be paraphrased in the complaint. You should keep the exhibits to use to
support or oppose a motion for summary judgment or at trial.
H. Change of Address. You must immediately notify the clerk and the opposing party or their
attorney 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.
I. 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. Rule 15(a) of the Federal Rules of Civil Procedure allows
you to file one amended complaint prior to any defendant filing an answer. After any defendant
has filed an answer, you must file a motion for leave to amend and lodge a proposed amended
complaint. Local Rule of Civil Procedure 15.1(a)(2) prohibits any amended pleading from
referencing any prior pleading. Further, any allegations or defendants not included in the
amended complaint are considered dismissed.
J. Letters and Motions. It is generally inappropriate to write a letter to any of the District
Judges, Magistrates Judges, or the staff of any of the judicial officers. The appropriate way to
communicate with these persons is by filing a written pleading or motion.
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II. Completing the Civil Rights Complaint Form:
HEADING:
1. Your Name. Print your name, prison or jail inmate number, and mailing address on
the lines provided.
2. Defendants. Print the names of each of your defendants. If you name more than four
defendants, you should print the name of one defendant and "see additional page for
defendants" in the space provided. On the additional page you must list the names of
all of the defendants. This additional page should be inserted after page 1 and numbered
as page "1-A" at the bottom of the page. The initial complaint must contain the names
of all of the parties (plaintiffs as well as defendants) in the heading (or on the additional
page if more than four defendants). See Rule 10(a) of the Federal Rules of Civil
Procedure.
3. Jury Demand. If you want a jury trial, you must write "JURY TRIAL DEMANDED"
on the line below "CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do
so will 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. Plaintiff. Print all of the requested information on the spaces provided. 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 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 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 the defendant(s) violated. The form provides space to
allege three separate counts (one violation per count). If you are alleging more than three
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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.
1. Counts. You must identify which civil right was violated. YOU MAY ALLEGE
THE VIOLATION OF ONLY ONE CIVIL RIGHTS CLAIM 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 in the space provided.
3. Supporting Facts. After you have identified which civil right was violated, you need
to 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
need to identify which defendant did what act. You also need to 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. Exhaustion of administrative remedies is a prerequisite
to filing a civil rights complaint. 42 U.S.C. § 1997e requires prisoners to exhaust the
available administrative remedies before being allowed to file a civil rights action.
Consequently, you must disclose whether you have exhausted the inmate grievance
procedures or administrative appeals for each count in your complaint. If one of your
counts is exempt from the grievance procedures or administrative appeals, fully explain
the exemption 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. Your signature
must be an original signature, not a photocopy.
FINAL NOTE
You should follow these instructions carefully. Failure to do so may result in your
complaint being stricken or dismissed by the court. All questions must be answered concisely
in the proper space on the form. If needed, you may attach no more than fifteen additional
pages. The form, however, 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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Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA

(Full Name of Plaintiff)

)
, )
)
)
) 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

Plaintiff,
vs.

(Full Name of Each Defendant)

Defendant(s).

A. JURISDICTION
1.

This Court has jurisdiction over this action pursuant to:
a. G 28 U.S.C. § 1343(a)(3); 42 U.S.C. § 1983
b. G 28 U.S.C. § 1331; Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971).
.
c. G Other: (Please specify.)

2.

Name of Plaintiff:
Present mailing address:

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

Institution/city where violation occurred:

Revised 4/9/06

.

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550/555

3.

Name of first Defendant:

. The first Defendant is employed as:
.

at
(Position and Title)

(Institution)

The first Defendant is sued in his/her: G individual capacity G official capacity (check one or both).
Explain how the first Defendant was acting under color of law:
.
4.

Name of second Defendant:

. The second Defendant is employed as:
at

.

(Position and Title)

(Institution)

The second Defendant is sued in his/her: G individual capacity G official capacity (check one or both).
Explain how the second Defendant was acting under color of law:
.
5.

Name of third Defendant:
at

. The third Defendant is employed as:
.

(Position and Title)

(Institution)

The third Defendant is sued in his/her: G individual capacity G official capacity (check one or both).
Explain how the third Defendant was acting under color of law:
.
6.

Name of fourth Defendant:
at

. The fourth Defendant is employed as:
.

(Position and Title)

(Institution)

The fourth Defendant is sued in his/her: G individual capacity G official capacity (check one or both).
Explain how the fourth Defendant was acting under color of law:
.
(If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page.)

B. PREVIOUS LAWSUITS
1.

Have you filed any other lawsuits while you were a prisoner?

2.

If your answer is "yes," how many lawsuits have you filed?
spaces provided below.

3.

First prior lawsuit:
a. Parties to previous lawsuit:
Plaintiff:
Defendants:

G Yes

G No

. Describe the previous lawsuits in the

.
.

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b.
c.
d.

Case or docket number:
Claims raised:

e.

Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?)

f.
g.
4.

Court: (If federal court, identify the district; if state court, identify the county.)

Approximate date lawsuit was filed:
Approximate date of disposition:

.
.

.
.
.

Second prior lawsuit:
a. Parties to previous lawsuit:
Plaintiff:
Defendants:

.
.

b.

Court: (If federal court, identify the district; if state court, identify the county.)

c.
d.

Case or docket number:
Claims raised:

e.

Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?)

f.
g.

Approximate date lawsuit was filed:
Approximate date of disposition:

.
.

.

5.

.
.
.

Third prior lawsuit:
a. Parties to previous lawsuit:
Plaintiff:
Defendants:

.
.

b.

Court: (If federal court, identify the district; if state court, identify the county.)

c.
d.

Case or docket number:
Claims raised:

e.

Disposition: (For example: Was the case dismissed? Was it appealed? Is it still pending?)

f.
g.

Approximate date lawsuit was filed:
Approximate date of disposition:

.
.

.
.
.
.

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

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C. CAUSE OF ACTION

1.

COUNT I
The following constitutional or other federal civil right has been violated by the Defendant(s):
.

2.

Count I involves: (Check only one; if your claim involves more than one issue, each issue should be stated
in a different count)
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 to violate your rights. State the facts clearly in your own words without citing legal
authority or arguments).

.
4.

Injury: (State how you have been 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
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?
d. If you did not submit or appeal a request for administrative relief to the highest level, briefly explain
why you did not.
.
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1.

COUNT II
The following constitutional or other federal civil right has been violated by the Defendant(s):
.

2.

Count II involves: (Check only one; if your claim involves more than one issue, each issue should be stated
in a different count)
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 to violate your rights. State the facts clearly in your own words without citing legal
authority or arguments).

.
4.

Injury: (State how you have been 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
G Yes G No
c. Did you appeal your request for relief on Count II to the highest level?
d. If you did not submit or appeal a request for administrative relief to the highest level, briefly explain
why you did not.
.
5

1.

COUNT III
The following constitutional or other federal civil right has been violated by the Defendant(s):
.

2.

Count III involves: (Check only one; if your claim involves more than one issue, each issue should be stated
in a different count)
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 to violate your rights. State the facts clearly in your own words without citing
legal authority or arguments).

.
4.

Injury: (State how you have been 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
G Yes G No
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 to the highest 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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D. REQUEST FOR RELIEF
State briefly exactly what you want the Court to do for you.

.

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 needed, you may attach no more
than fifteen additional pages. The form, however, must be completely filled in to the extent applicable.

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