Tull v. Arpaio et al

Filing 9

ORDER: The Judgment 7 entered March 25, 2014 is vacated; The Clerk of Court must re-open this case; The First Amended Complaint 8 is dismissed for failure to state a claim; Plaintiff has 30 days from the date this Order is filed to file a secon d amended complaint 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 6/10/2014. (ALS)

1
2

MD

WO

3
4
5
6

IN THE UNITED STATES DISTRICT COURT

7

FOR THE DISTRICT OF ARIZONA

8
9

Clarence Tull,

10
11
12
13

No. CV 13-2594-PHX-DGC (BSB)
Plaintiff,

v.

ORDER

Joseph Arpaio, et al.,
Defendants.

14
15

On December 19, 2013, Plaintiff Clarence Tull, who is confined in the Maricopa

16

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

17

and an Application to Proceed In Forma Pauperis. In a February 5, 2014 Order, the

18

Court granted the Application to Proceed and dismissed the Complaint because Plaintiff

19

had failed to state a claim. The Court gave Plaintiff 30 days to file an amended complaint

20

that cured the deficiencies identified in the Order. Plaintiff did not file an amended

21

complaint within 30 days, and, pursuant to the Court’s February 5, 2014 Order, the Clerk

22

entered Judgment (Doc. 7) on March 24, 2014.

23
24

First Amended Complaint is dated March 11, 2014, before the Clerk’s entry of Judgment.

25

Therefore, in an abundance of caution and in the interest of justice, the Court will treat

26

the First Amended Complaint as though it were received before the Judgment issued. See

27

Houston v. Lack, 487 U.S. 266 (1988) (under the “prison mailbox rule” a document is

28

JDDL-K

On March 25, 2014, Plaintiff filed his First Amended Complaint (Doc. 8). The

deemed “filed” when delivered by the prisoner to a prison official for mailing.).

1

Accordingly, the Court will vacate the March 24, 2014 Judgment, re-open this case, and

2

will screen Plaintiff’s First Amended Complaint.

3

Amended Complaint with leave to amend.

4

I.

The Court will dismiss the First

Statutory Screening of Prisoner Complaints

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

does not demand detailed factual allegations, “it demands more than an unadorned, the-

14

defendant-unlawfully-harmed-me accusation.”

15

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

16

conclusory statements, do not suffice.” Id.

Ashcroft v. Iqbal, 556 U.S. 662, 678

17

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

18

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

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

at 681.

27
28

JDDL-K

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,

-2-

1

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

2

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

3

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

4

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

5

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

6

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

7

Plaintiff’s First Amended Complaint will be dismissed for failure to state a claim, but

8

because it may possibly be amended to state a claim, the Court will dismiss it with leave

9

to amend.

10

II.

11
12

First Amended Complaint
Plaintiff names Maricopa County Sheriff Joseph Arpaio as the Defendant in his

First Amended Complaint. Plaintiff seeks damages.

13

In Count One, Plaintiff alleges that Defendant Arpaio requires three inmates per

14

cell. Plaintiff asserts that he has been in Towers Jail for 18 months and has had three

15

men in his cell, which restricts his access to the toilet and water. There is no toilet brush,

16

one person sits on the toilet to eat, it is unsanitary, and there is no proper ventilation.

17

In Count Two, Plaintiff alleges that for one month at Durango Jail he was exposed

18

to black mold in the showers and asbestos. He alleges that Defendant Arpaio orders that

19

inmates be housed at this location and that Arpaio “is aware and doesn’t fix problem[s].”

20

In Count Three, Plaintiff alleges that “food [is] not fit for eating Sheriff Arpaio

21

orders of food that is given to inmates.” Plaintiff further alleges that “some in Feb has

22

had fecal matter[,] rotten oranges, rocks [and] other objects.” Plaintiff asserts that it is

23

“not a proper 2000 cal diet.”

24

III.

Failure to State a Claim

25
26

(2) under color of state law (3) deprived him of federal rights, privileges or immunities

27

and (4) caused him damage. Thornton v. City of St. Helens, 425 F.3d 1158, 1163-64 (9th

28

JDDL-K

To prevail in a § 1983 claim, a plaintiff must show that (1) acts by the defendants

Cir. 2005) (quoting Shoshone-Bannock Tribes v. Idaho Fish & Game Comm’n, 42 F.3d

-3-

1

1278, 1284 (9th Cir. 1994)). In addition, a plaintiff must allege that he suffered a specific

2

injury as a result of the conduct of a particular defendant and he must allege an

3

affirmative link between the injury and the conduct of that defendant. Rizzo v. Goode,

4

423 U.S. 362, 371-72, 377 (1976).

5

Plaintiff sues Maricopa County Sheriff Arpaio. While Arpaio may be sued for

6

constitutional violations, Plaintiff fails to state a claim against him. “A plaintiff must

7

allege facts, not simply conclusions, that show that an individual was personally involved

8

in the deprivation of his civil rights.” Barren v. Harrington, 152 F.3d 1193, 1194 (9th

9

Cir. 1998). For an individual to be liable in his official capacity, a plaintiff must allege

10

that the official acted as a result of a policy, practice, or custom. See Cortez v. County of

11

Los Angeles, 294 F.3d 1186, 1188 (9th Cir. 2002) (citation omitted). Further, there is no

12

respondeat superior liability under § 1983, so a defendant’s position as the supervisor of

13

someone who allegedly violated a plaintiff’s constitutional rights does not make him

14

liable. Monell v. Dep’t of Soc. Servs. of New York, 436 U.S. 658, 691 (1978); Taylor v.

15

List, 880 F.2d 1040, 1045 (9th Cir. 1989) (citation omitted).

16

individual capacity “is only liable for constitutional violations of his subordinates if the

17

supervisor participated in or directed the violations, or knew of the violations and failed

18

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

A supervisor in his

19
20

Plaintiff merely states that Defendant Arpaio requires that three inmates be housed in a

21

cell, that Arpaio orders that inmates be housed at Durango Jail and does not fix problems,

22

and that “Sheriff Arpaio orders of food that is given to inmates.” These allegations are

23

insufficient to support that Defendant Arpaio directly violated Plaintiff’s constitutional

24

rights or that a specific policy, custom or practice promulgated or endorsed by Arpaio led

25

to the violations of Plaintiff’s constitutional rights, as opposed to the rights of inmates in

26

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

27

519, 520-21 (1972), conclusory and vague allegations will not support a cause of action.

28

JDDL-K

Plaintiff’s allegations against Defendant Arpaio are vague and conclusory.

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

-4-

1

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

2

claim that were not initially pled. Id. Accordingly, Plaintiff fails to state a claim against

3

Defendant Arpaio and he will be dismissed.

4

IV.

Leave to Amend

5

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

6

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

7

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

8

Clerk of Court will mail Plaintiff a court-approved form to use for filing a second

9

amended complaint. If Plaintiff fails to use the court-approved form, the Court may

10

strike the second amended complaint and dismiss this action without further notice to

11

Plaintiff.

12

If Plaintiff files an amended complaint, Plaintiff must write short, plain statements

13

telling the Court: (1) the constitutional right Plaintiff believes was violated; (2) the name

14

of the Defendant who violated the right; (3) exactly what that Defendant did or failed to

15

do; (4) how the action or inaction of that Defendant is connected to the violation of

16

Plaintiff’s constitutional right; and (5) what specific injury Plaintiff suffered because of

17

that Defendant’s conduct. See Rizzo, 423 U.S. at 371-72, 377.

18

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

19

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

20

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

21

failure to state a claim.

22

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

23

dismissed.

Conclusory allegations that a Defendant or group of

24
25

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

26

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

27

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

28

JDDL-K

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

claim per count.

-5-

1

A second amended complaint supersedes the original Complaint and First

2

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

3

Roach Studios v. Richard Feiner & Co., 896 F.2d 1542, 1546 (9th Cir. 1990). After

4

amendment, the Court will treat the original Complaint and First Amended Complaint as

5

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

6

original complaint or first amended complaint and that was voluntarily dismissed or was

7

dismissed without prejudice is waived if it is not alleged in a second amended complaint.

8

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

9

V.

Warnings

10

A.

11

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

12

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

13

intends to pay the balance or (2) show good cause, in writing, why he cannot. Failure to

14

comply may result in dismissal of this action.

Release

15

B.

16

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

17

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

18

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

19

dismissal of this action.

Address Changes

20

C.

21

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

22

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

23

notice to Plaintiff.

Copies

24
25

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

26

claim, if Plaintiff fails to file a second amended complaint correcting the deficiencies

27

identified in this Order, the dismissal may count as a “strike” under the “3-strikes”

28

JDDL-K

D.

provision of 28 U.S.C. § 1915(g). Under the 3-strikes provision, a prisoner may not bring

Possible “Strike”

-6-

1

a civil action or appeal a civil judgment in forma pauperis under 28 U.S.C. § 1915 “if the

2

prisoner has, on 3 or more prior occasions, while incarcerated or detained in any facility,

3

brought an action or appeal in a court of the United States that was dismissed on the

4

grounds that it is frivolous, malicious, or fails to state a claim upon which relief may be

5

granted, unless the prisoner is under imminent danger of serious physical injury.” 28

6

U.S.C. § 1915(g).

7

E.

8

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

9

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

10

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

11

order of the Court).

12

IT IS ORDERED:

13
14
15

(1)

Possible Dismissal

The Judgment (Doc. 7) entered March 25, 2014 is vacated. The Clerk of

Court must re-open this case.
(2)

The First Amended Complaint (Doc. 8) is dismissed for failure to state a

16

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

17

complaint in compliance with this Order.

18

(3)

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

19

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

20

with prejudice that states that the dismissal may count as a “strike” under 28 U.S.C.

21

§ 1915(g).

22

(4)

23
24

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

civil rights complaint by a prisoner.
Dated this 10th day of June, 2014.

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 and Administrative Fees. The total fees for this action are $400.00 ($350.00 filing fee
plus $50.00 administrative fee). If you are unable to immediately pay the fees, you may request
leave to proceed in forma pauperis. Please review the “Information for Prisoners Seeking Leave
to Proceed with a (Non-Habeas) Civil Action in Federal Court In Forma Pauperis Pursuant to 28
U.S.C. § 1915” for additional instructions.
5. Original and Judge’s Copy. You must send an original plus one copy of your complaint and of
any other documents submitted to the Court. You must send one additional copy to the Court if you
wish to have a file-stamped copy of the document returned to you. All copies must be identical to
the original. Copies may be legibly handwritten.
6. Where to File. You should file your complaint in the division where you were confined when
your rights were allegedly violated. See LRCiv 5.1(a) and 77.1(a). If you were confined in
Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. If you were confined
in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott Division. If you
were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file in the Tucson
Division. Mail the original and one copy of the complaint with the $400 filing and
administrative fees or the application to proceed in forma pauperis to:

Revised 5/1/2013

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 court-approved
civil rights complaint form. You may file one amended complaint without leave (permission) of
Court before any defendant has answered your original complaint. See Fed. R. Civ. P. 15(a). After
any defendant has filed an answer, you must file a motion for leave to amend and lodge (submit) a
proposed amended complaint. LRCiv 15.1. In addition, an amended complaint may not incorporate
by reference any part of your prior complaint. LRCiv 15.1(a)(2). Any allegations or defendants
not included in the amended complaint are considered dismissed. All amended complaints are
subject to screening under the Prison Litigation Reform Act; screening your amendment will take
additional processing time.
10. Exhibits. You should not submit exhibits with the complaint or amended complaint. Instead,
the relevant information should be paraphrased. You should keep the exhibits to use to support or
oppose a motion to dismiss, a motion for summary judgment, or at trial.
11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff of
any judge. The only appropriate way to communicate with the Court is by filing a written pleading
or motion.
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 “1-A” at the bottom.
3. Jury Demand. If you want a jury trial, you must write “JURY TRIAL DEMANDED” in
the space below “CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do so may
result in the loss of the right to a jury trial. A jury trial is not available if you are seeking
only injunctive relief.
Part A. JURISDICTION:
1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. § 1983
for state, county, or city defendants; “Bivens v. Six Unknown Federal Narcotics Agents” for
federal defendants; or “other.” If you mark “other,” identify the source of that authority.
2. Location. Identify the institution and city where the alleged violation of your rights
occurred.
3. Defendants. Print all of the requested information about each of the defendants in the
spaces provided. If you are naming more than four defendants, you must provide the
necessary information about each additional defendant on separate pages labeled “2-A,” “2B,” etc., at the bottom. Insert the additional page(s) immediately behind page 2.
Part B. PREVIOUS LAWSUITS:
You must identify any other lawsuit you have filed in either state or federal court while you
were a prisoner. Print all of the requested information about each lawsuit in the spaces provided.
If you have filed more than three lawsuits, you must provide the necessary information about each
additional lawsuit on a separate page. Label the page(s) as “2-A,” “2-B,” etc., at the bottom of the
page and insert the additional page(s) immediately behind page 2.
Part C. CAUSE OF ACTION:
You must identify what rights each defendant violated. The form provides space to allege
three separate counts (one violation per count). If you are alleging more than three counts, you
must provide the necessary information about each additional count on a separate page. Number
the additional pages “5-A,” “5-B,” etc., and insert them immediately behind page 5. Remember that
you are limited to a total of fifteen additional pages.

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 5/1/2013

1

550/555

B. DEFENDANTS
1.

Name of first Defendant:

. The first Defendant is employed as:
at

.

(Position and Title)
2.

(Institution)
. The second Defendant is employed as:

Name of second Defendant:
at

.

(Position and Title)
3.

(Institution)

Name of third Defendant:

. The third Defendant is employed as:
at

.

(Position and Title)
4.

(Institution)

Name of fourth Defendant:
at
(Position and Title)

. The fourth Defendant is employed as:
.
(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 at your
G Yes G No
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 at your
G Yes G No
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