Rokosiga v. Zelenka et al

Filing 7

ORDER: Within 30 days of the date this Order is filed, Plaintiff must either pay the $400.00 filing and administrative fees or file a completed Motion to Proceed In Forma Pauperis. If Plaintiff fails to either pay or file a completed Motion w ithin 30 days, the Clerk of Court must enter a judgment of dismissal of this action without prejudice and without further notice to Plaintiff. The Complaint 1 is dismissed without prejudice. Plaintiff has 30 days from the date this Order is filed to file an amended complaint on the court-approved form. 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 without prejudice. The Clerk of Court must mail Plaintiff a court-approved form for filing a civil rights complaint by a prisoner and a form for filing a Motion to Proceed In Forma Pauperis and Supporting Information. Signed by Senior Judge Robert C Broomfield on 11/22/2013. (ALS)

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IN THE UNITED STATES DISTRICT COURT

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FOR THE DISTRICT OF ARIZONA

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Savenaca Mikaele Rokosiga,

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Plaintiff,

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No. CV 13-1738-PHX-RCB (SPL)

vs.

ORDER

Martin F. Zelenka, et al.,

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Defendants.

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Plaintiff Savenaca Mikaele Rokosiga, who was formerly confined in the Pinal

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County Detention Facility as an Immigration and Customs Enforcement detainee, has

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filed a pro se civil rights Complaint pursuant to 42 U.S.C. § 1983. Because Plaintiff was

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an immigration detainee and sues federal actors, the Court will construe the Complaint as

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filed pursuant to Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics,

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403 U.S. 388 (1971). See Martin v. Sias, 88 F.3d 774, 775 (9th Cir. 1996) (“Actions

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under § 1983 and those under Bivens are identical save for the replacement of a state

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actor under § 1983 by a federal actor under Bivens.”).

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Plaintiff has not paid the filing fee or filed a proper Motion to Proceed In Forma

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Pauperis. The Court will give Plaintiff 30 days to pay the fee or file a completed Motion

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to Proceed In Forma Pauperis. The Court will also dismiss the Complaint and give

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Plaintiff 30 days to file a new Complaint on the court-approved form.

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I.

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JDDL

Payment of Filing Fee
Because Plaintiff was an immigration detainee at the time he filed the Complaint,

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he is not subject to the provisions of the Prison Litigation Reform Act. Andrews v. King,

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398 F.3d 1113, 1122 (9th Cir. 2005); Agyeman v. INS, 296 F.3d 871, 885-86 (9th Cir.

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2002). However, to proceed in federal court, Plaintiff must either pay the $350.00 filing

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fee and $50.00 administrative fee or file a Motion to Proceed In Forma Pauperis.

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Plaintiff will be permitted 30 days to do so.

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II.

Failure to File Complaint on Court-Approved Form

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Pursuant to Local Rule of Civil Procedure 3.4(a), “[a]ll complaints and

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applications to proceed in forma pauperis by incarcerated persons shall be signed and

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legibly written or typewritten on forms approved by the Court.” Plaintiff has not filed his

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Complaint on the court-approved form. The Court will therefore dismiss the Complaint

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and grant Plaintiff 30 days to file an amended complaint on the court-approved form.

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

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

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Plaintiff should note that mere negligent failure of a prison official to protect an

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inmate from another inmate is not actionable under § 1983 or Bivens. Davidson v.

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Cannon, 474 U.S. 344 (1986). A prison official violates the Eighth Amendment in

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failing to protect one inmate from another only when two conditions are met. First, the

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alleged constitutional deprivation must be, objectively, “sufficiently serious;” the

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official’s act or omission must result in the denial of “the minimal civilized measure of

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life=s necessities.” Farmer v. Brennan, 511 U.S. 825, 834 (1994). Second, the prison

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official must have a “sufficiently culpable state of mind,” i.e., he must act with deliberate

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indifference to inmate health or safety. Id. In defining “deliberate indifference” in this

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context, the Supreme Court has imposed a subjective test:

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the official must both be aware of the facts from which the
inference could be drawn that a substantial risk of serious
harm exists, and he must also draw the inference.

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Id. at 839 (emphasis supplied).

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An amended complaint supersedes the original Complaint. Ferdik v. Bonzelet,

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

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F.2d 1542, 1546 (9th Cir. 1990). After amendment, the original Complaint will be

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

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the original Complaint is waived if it is not raised in the amended complaint. King v.

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Atiyeh, 814 F.2d 565, 567 (9th Cir. 1987).

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III.

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Warnings
A.

Address Changes

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

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

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

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dismissal of this action.

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B.

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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

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notice to Plaintiff.

Copies

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C.

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

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

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

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order of the Court).

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IT IS ORDERED:

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(1)

Possible Dismissal

Within 30 days of the date this Order is filed, Plaintiff must either pay the

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$400.00 filing and administrative fees or file a completed Motion to Proceed In Forma

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Pauperis.

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(2)

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If Plaintiff fails to either pay the $400.00 filing and administrative fees or

file a completed Motion to Proceed In Forma Pauperis within 30 days, the Clerk of Court

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must enter a judgment of dismissal of this action without prejudice and without further

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notice to Plaintiff.

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(3)

The Complaint (Doc. 1) is dismissed without prejudice. Plaintiff has 30

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days from the date this Order is filed to file an amended complaint on the court-approved

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form.

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(4)

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

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

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prejudice.

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(5)

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

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civil rights complaint by a prisoner and a form for filing a Motion to Proceed In Forma

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Pauperis and Supporting Information.

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DATED this 22nd day of November, 2013.

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JDDL

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Name
Address
City, State, Zip
Telephone number

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IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA

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Plaintiff,

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vs.

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Defendant.

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CV
MOTION TO PROCEED
IN FORMA PAUPERIS and
SUPPORTING INFORMATION

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I, ___________________________________, declare that I am the Plaintiff in this action;

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that I hereby request to proceed without being required to prepay fees, costs or give security

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therefore. I state that, because of my poverty, I am unable to pay the fees of said proceeding;

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that I believe I am entitled to relief.

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In further support of this application, I answer the following questions:

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1.

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Are you presently employed?
a.

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Yes

No

If the answer is "yes", state the amount of your salary or wages per month and
give the name and address of your employer.

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b.

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If the answer is "no", state the date of last employment and the amount of the
salary and wages per month which you received.

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2.

Is your spouse employed?
a.

Yes

No

If the answer is "yes", state the amount of your spouse's salary or wages per
month and give the name and address of your spouse's employer.

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ATTACHMENT 6

b.

If the answer is "no", state the date of last employment and the amount of the
salary and wages per month which your spouse received.

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3.

Have you received within the past twelve months any money from any of the following
sources?

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a.

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Rent payments, interest or dividends

Yes

No

Pensions, annuities or life insurance payments Yes

No

Gifts or inheritances

Yes

No

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No

d.

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Yes

c.

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Business or other form of self employment

b.

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Any other sources

Yes

No

If the answer to any of the above is "yes", describe each source of money and state the

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amount received from each during the past twelve months.

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4.

If the answer is "yes", what is the amount of money you own in cash _________,

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checking account ___________, savings account ___________.

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5.

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No

If the answer is "yes", describe and give estimated value of each.

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Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable
property (excluding household furnishing and clothing)? Yes

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Do you own any cash, or do you have money in checking or savings accounts?

6.

List the number of persons who are dependent upon you for support, state your
relationship to those persons, and indicate how much you contribute towards their
support.
I declare under penalty of perjury that the forgoing is true and correct.
DATED this ___ day of ________________, 200__.

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______________________________
Your signature in ink
______________________________
Your name typed or printed
______________________________
______________________________
Address
_______________________________
Telephone Number

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IN THE UNITED STATES DISTRICT COURT

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FOR THE DISTRICT OF ARIZONA

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Plaintiff,

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vs.

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Defendant.

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CV
ORDER

I, ___________________________________, District Judge/Magistrate Judge of the United
States District Court for the District of Arizona, hereby:
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GRANT the application for leave to proceed in forma pauperis, without prepayment of costs
or fees or the necessity of giving security therefore. Plaintiff shall be responsible for service

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by waiver or of the summons and complaint.

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GRANT the application for leave to proceed in forma pauperis, without prepayment of costs

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or fees or the necessity of giving security therefore. Service by waiver or of the summons and
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complaint shall be at government expense on the defendants by the U.S. Marshal or his
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authorized representative.
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DENY the application for leave to proceed in forma pauperis without prepayment of costs
or fees or the necessity of giving security therefore. Plaintiff shall have 10 days from the
entry of this Order to pay the filing fee of $350.00. The Clerk of Court is directed to enter

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ATTACHMENT 7

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dismissal of this action without further notice if Plaintiff fails to pay the filing fee of $350.00

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within 10 days of the entry of this Order.

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The Clerk shall forthwith notify the Plaintiff of the entry of this Order.

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DATED this ___ day of ________________, 200__.

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United States District/Magistrate Judge

FEDERAL RULES OF CIVIL PROCEDURE

Rule 4. Summons
(a) Form.
The summons shall be signed by the clerk, bear the seal of the court, identify the court and the
parties, be directed to the defendant, and state the name and address of the plaintiff's attorney or, if
unrepresented, of the plaintiff. It shall also state the time within which the defendant must appear
and defend, and notify the defendant that failure to do so will result in a judgment by default against
the defendant for the relief demanded in the complaint. The court may allow a summons to be
amended.
(b) Issuance
Upon or after filing the complaint, the plaintiff may present a summons to the clerk for signature and
seal. If the summons is in proper form, the clerk shall sign, seal, and issue it to the plaintiff for
service on the defendant. A summons, or a copy of the summons if addressed to multiple defendants,
shall be issued for each defendant to be served.
(c) Service with Complaint; by Whom Made.
(1) A summons shall be served together with a copy of the complaint. The plaintiff is responsible
for service of a summons and complaint within the time allowed under subdivision (m) and shall
furnish the person effecting service with the necessary copies of the summons and complaint.
(2) Service may be effected by any person who is not a party and who is at least 18 years of age. At
the request of the plaintiff, however, the court may direct that service be effected by a United States
marshal, deputy United States marshal, or other person or officer specially appointed by the court
for the purpose. Such an appointment must be made when the plaintiff is authorized to proceed in
forma pauperis pursuant to 28 U.S.C. § 1915 or is authorized to proceed as a seaman under 28
U.S.C. § 1916.
(d) Waiver of Service; Duty to Save Costs of Service; Request to Waive.
(1) A defendant who waives service of a summons does not thereby waive any objection to the
venue or to the jurisdiction of the court over the person of the defendant.
(2) An individual, corporation, or association that is subject to service under subdivision (e) , (f) ,
or (h) and that receives notice of an action in the manner provided in this paragraph has a duty to
avoid unnecessary costs of serving the summons. To avoid costs, the plaintiff may notify such a
defendant of the commencement of the action and request that the defendant waive service of a
summons. The notice and request
ATTACHMENT 8

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

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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.
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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.
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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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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
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)
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

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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.

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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.
.
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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:

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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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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.

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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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