Lewis v. Maricopa County Jail

Filing 6

ORDER granting Plaintiff's 2 Motion for Leave to Proceed In Forma Pauperis. As required by the accompanying Order to the appropriate government agency, Plaintiff must pay the $350.00 filing fee and is not assessed an initial partial f iling fee. The First Amended Complaint 5 is dismissed for failure to state a claim. Plaintiff has 30 days from the date this Order is filed to file a second amended complaint in compliance with this Order. If Plaintiff fails to file a second ame nded 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) and deny any pending unrelated motions as moot. The Clerk of Court must mail Plaintiff a court-approved form for filing a civil rights complaint by a prisoner. Signed by Senior Judge David G Campbell on 4/28/2021. (CLB)

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1 2 SC WO 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Lawrence Lewis, Jr., 10 11 12 No. CV 21-00424-PHX-DGC (JFM) Plaintiff, v. ORDER Maricopa County Jail, et al., 13 Defendants. 14 15 Plaintiff Lawrence Lewis, Jr., who is confined in a Maricopa County Jail, filed a pro 16 se civil rights Complaint pursuant to 42 U.S.C. § 1983 (Doc. 1) and an Application to 17 Proceed In Forma Pauperis (Doc. 2). 18 Complaint (Doc. 5), which supersedes the Complaint. The Court will dismiss the First 19 Amended Complaint with leave to amend. 20 I. Plaintiff subsequently filed a First Amended Application to Proceed In Forma Pauperis and Filing Fee 21 22 U.S.C. § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. 23 § 1915(b)(1). The Court will not assess an initial partial filing fee. Id. The statutory filing 24 fee will be collected monthly in payments of 20% of the previous month’s income credited 25 to Plaintiff’s trust account each time the amount in the account exceeds $10.00. 28 U.S.C. 26 § 1915(b)(2). The Court will enter a separate Order requiring the appropriate government 27 agency to collect and forward the fees according to the statutory formula. 28 JDDL-K The Court will grant Plaintiff’s Application to Proceed In Forma Pauperis. 28 .... 1 II. Statutory Screening of Prisoner Complaints 2 The Court is required to screen complaints brought by prisoners seeking relief 3 against a governmental entity or an officer or an employee of a governmental entity. 28 4 U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff 5 has raised claims that are legally frivolous or malicious, that fail to state a claim upon which 6 relief may be granted, or that seek monetary relief from a defendant who is immune from 7 such relief. 28 U.S.C. § 1915A(b)(1)–(2). 8 A pleading must contain a “short and plain statement of the claim showing that the 9 pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 does 10 not demand detailed factual allegations, “it demands more than an unadorned, the- 11 defendant-unlawfully-harmed-me accusation.” 12 (2009). “Threadbare recitals of the elements of a cause of action, supported by mere 13 conclusory statements, do not suffice.” Id. Ashcroft v. Iqbal, 556 U.S. 662, 678 14 “[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a 15 claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly, 16 550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual content 17 that allows the court to draw the reasonable inference that the defendant is liable for the 18 misconduct alleged.” Id. “Determining whether a complaint states a plausible claim for 19 relief [is] . . . a context-specific task that requires the reviewing court to draw on its judicial 20 experience and common sense.” Id. at 679. Thus, although a plaintiff’s specific factual 21 allegations may be consistent with a constitutional claim, a court must assess whether there 22 are other “more likely explanations” for a defendant’s conduct. Id. at 681. 23 But as the United States Court of Appeals for the Ninth Circuit has instructed, courts 24 must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 342 25 (9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less stringent 26 standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. Pardus, 551 27 U.S. 89, 94 (2007) (per curiam)). 28 JDDL-K If the Court determines that a pleading could be cured by the allegation of other -2- 1 facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal 2 of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) (en banc). 3 Plaintiff’s First Amended Complaint will be dismissed for failure to state a claim, but 4 because it may possibly be amended to state a claim, the Court will dismiss it with leave 5 to amend. 6 III. First Amended Complaint 7 In his two-count First Amended Complaint, Plaintiff alleges claims for threat to 8 safety and unconstitutional conditions of confinement. Plaintiff names Maricopa County 9 Sheriff Paul Penzone as the sole Defendant. Plaintiff seeks compensatory relief. 10 In Count I, Plaintiff alleges that he has been held in jail for almost two months. 11 Plaintiff alleges that he has been breathing black mold and asbestos, which have resulted 12 in him developing a dry cough and suffering nosebleeds and chest pain. He further alleges 13 that due to COVID-19, “[t]hey automatically” assume his symptoms are caused by 14 COVID-19, but they are not. Plaintiff alleges that he has been tested for COVID-19 15 numerous times at the Jail, but his results have been negative. 16 In Count II, Plaintiff alleges that while held in Jail, he has not been provided 17 personal protective equipment (PPE), the lack of a “Person Policy Initiative” might place 18 him at risk of catching COVID-19, he lacks access to hand sanitizer, he has not received a 19 new mask each day, and there have been no daily showers for more than two weeks due to 20 a security override. 21 IV. Failure to State a Claim 22 23 (2) under color of state law (3) deprived him of federal rights, privileges or immunities and 24 (4) caused him damage. Thornton v. City of St. Helens, 425 F.3d 1158, 1163-64 (9th Cir. 25 2005) (quoting Shoshone-Bannock Tribes v. Idaho Fish & Game Comm’n, 42 F.3d 1278, 26 1284 (9th Cir. 1994)). In addition, a plaintiff must allege that he suffered a specific injury 27 as a result of the conduct of a particular defendant and he must allege an affirmative link 28 JDDL-K To prevail in a § 1983 claim, a plaintiff must show that (1) acts by the defendants between the injury and the conduct of that defendant. Rizzo v. Goode, 423 U.S. 362, 371- -3- 1 72, 377 (1976). 2 A. 3 Plaintiff names only Maricopa County Sheriff Penzone as a Defendant. While 4 Penzone may be sued under § 1983, Plaintiff fails to allege any facts against Penzone. To 5 state a claim against Penzone, Plaintiff must allege facts to support that Penzone directly 6 violated Plaintiff’s constitutional rights or that Plaintiff’s constitutional rights were 7 violated pursuant to a policy or custom implemented or condoned by Penzone. There is no 8 respondeat superior liability under § 1983, and therefore a defendant’s position as the 9 supervisor of persons who allegedly violated a plaintiff’s constitutional rights does not 10 impose liability. Monell v. Dep’t of Soc. Servs., 436 U.S. 658 (1978); Hamilton v. Endell, 11 981 F.2d 1062, 1067 (9th Cir. 1992); Taylor v. List, 880 F.2d 1040, 1045 (9th Cir. 1989). 12 “Because vicarious liability is inapplicable to . . . § 1983 suits, a plaintiff must plead that 13 each Government-official defendant, through the official’s own individual actions, has 14 violated the Constitution.” Iqbal, 556 U.S. at 676. Because Plaintiff fails to allege any 15 facts against Penzone, Plaintiff fails to state a claim against him. Penzone 16 B. 17 A pretrial detainee has a right under the Due Process Clause of the Fourteenth 18 Amendment to be free from punishment prior to an adjudication of guilt. Bell v. Wolfish, 19 441 U.S. 520, 535 (1979). “Pretrial detainees are entitled to ‘adequate food, clothing, 20 shelter, sanitation, medical care, and personal safety.’” Alvarez-Machain v. United States, 21 107 F.3d 696, 701 (9th Cir. 1996) (quoting Hoptowit v. Ray, 682 F.2d 1237, 1246 (9th Cir. 22 1982)). 23 individual defendant, a pretrial detainee must allege facts that show: 24 25 26 27 28 JDDL-K Threat to Safety/Conditions of Confinement To state a claim of unconstitutional conditions of confinement against an (i) the defendant made an intentional decision with respect to the conditions under which the plaintiff was confined; (ii) those conditions put the plaintiff at substantial risk of suffering serious harm; (iii) the defendant did not take reasonable available measures to abate that risk, even though a reasonable official in the circumstances would have appreciated the high degree of risk involved—making the consequences of the defendant’s conduct obvious; and (iv) by not taking such measures, the defendant caused the plaintiff’s injuries. -4- 1 Gordon v. County of Orange, 888 F.3d 1118, 1125 (9th Cir. 2018). 2 Whether the conditions and conduct rise to the level of a constitutional violation is 3 an objective assessment that turns on the facts and circumstances of each particular case. 4 Id.; Hearns v. Terhune, 413 F.3d 1036, 1042 (9th Cir. 2005). However, “a de minimis 5 level of imposition” is insufficient. Bell, 441 U.S. at 539 n.21. In addition, the “‘mere lack 6 of due care by a state official’ does not deprive an individual of life, liberty, or property 7 under the Fourteenth Amendment.” Castro v. County of Los Angeles, 833 F.3d 1060, 1071 8 (9th Cir. 2016) (quoting Daniels v. Williams, 474 U.S. 327, 330-31 (1986)). Thus, a 9 plaintiff must “prove more than negligence but less than subjective intent—something akin 10 to reckless disregard.” Id. 11 Plaintiff alleges claims for unconstitutional conditions of confinement and threat to 12 safety. Plaintiff fails to allege facts to support that Sheriff Penzone, or anyone else, acted 13 with reckless disregard to allegedly unconstitutional conditions or to a substantial threat to 14 Plaintiff’s safety. Plaintiff asserts that “black mold” or asbestos are causing his symptoms, 15 but he fails to allege facts to support any connection between his symptoms and allegedly 16 breathing black mold or being exposed to asbestos. Absent more, Plaintiff fails to allege 17 facts to state a claim for either unconstitutional conditions or a threat to safety, and his 18 claims will be dismissed. 19 V. Leave to Amend 20 For the foregoing reasons, Plaintiff’s First Amended Complaint will be dismissed 21 for failure to state a claim upon which relief may be granted. Within 30 days, Plaintiff may 22 submit a second amended complaint to cure the deficiencies outlined above. The Clerk of 23 Court will mail Plaintiff a court-approved form to use for filing a second amended 24 complaint. If Plaintiff fails to use the court-approved form, the Court may strike the second 25 amended complaint and dismiss this action without further notice to Plaintiff. 26 27 Amended Complaint.” The second amended complaint must be retyped or rewritten in its 28 JDDL-K Plaintiff must clearly designate on the face of the document that it is the “Second entirety on the court-approved form and may not incorporate any part of the original -5- 1 Complaint or First Amended Complaint by reference. Plaintiff may include only one claim 2 per count. 3 A second amended complaint supersedes the original Complaint and First Amended 4 Complaint. Ferdik v. Bonzelet, 963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. 5 Richard Feiner & Co., 896 F.2d 1542, 1546 (9th Cir. 1990). After amendment, the Court 6 will treat the original Complaint and First Amended Complaint as nonexistent. Ferdik, 7 963 F.2d at 1262. Any cause of action that was raised in the original Complaint or First 8 Amended Complaint and that was voluntarily dismissed or was dismissed without 9 prejudice is waived if it is not alleged in a second amended complaint. Lacey v. Maricopa 10 County, 693 F.3d 896, 928 (9th Cir. 2012) (en banc). 11 VI. Warnings 12 A. 13 If Plaintiff is released while this case remains pending, and the filing fee has not 14 been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court 15 that he intends to pay the unpaid balance of his filing fee within 120 days of his release or 16 (2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may 17 result in dismissal of this action. Release 18 B. 19 Plaintiff must file and serve a notice of a change of address in accordance with Rule 20 83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion for other 21 relief with a notice of change of address. Failure to comply may result in dismissal of this 22 action. Address Changes Possible “Strike” 23 24 Because the First Amended Complaint has been dismissed for failure to state a 25 claim, if Plaintiff fails to file a second amended complaint correcting the deficiencies 26 identified in this Order, the dismissal may count as a “strike” under the “3-strikes” 27 provision of 28 U.S.C. § 1915(g). Under the 3-strikes provision, a prisoner may not bring 28 JDDL-K C. a civil action or appeal a civil judgment in forma pauperis under 28 U.S.C. § 1915 “if the -6- 1 prisoner has, on 3 or more prior occasions, while incarcerated or detained in any facility, 2 brought an action or appeal in a court of the United States that was dismissed on the 3 grounds that it is frivolous, malicious, or fails to state a claim upon which relief may be 4 granted, unless the prisoner is under imminent danger of serious physical injury.” 28 5 U.S.C. § 1915(g). 6 D. 7 If Plaintiff fails to timely comply with every provision of this Order, including these 8 warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d 9 at 1260-61 (a district court may dismiss an action for failure to comply with any order of Possible Dismissal 10 the Court). 11 IT IS ORDERED: 12 (1) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 2) is granted. 13 (2) As required by the accompanying Order to the appropriate government 14 agency, Plaintiff must pay the $350.00 filing fee and is not assessed an initial partial filing 15 fee. 16 (3) The First Amended Complaint (Doc. 5) is dismissed for failure to state a 17 claim. Plaintiff has 30 days from the date this Order is filed to file a second amended 18 complaint in compliance with this Order. 19 (4) If Plaintiff fails to file a second amended complaint within 30 days, the Clerk 20 of Court must, without further notice, enter a judgment of dismissal of this action with 21 prejudice that states that the dismissal may count as a “strike” under 28 U.S.C. § 1915(g) 22 and deny any pending unrelated motions as moot. 23 24 25 (5) The Clerk of Court must mail Plaintiff a court-approved form for filing a civil rights complaint by a prisoner. Dated this 28th day of April, 2021. 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 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 $402.00 ($350.00 filing fee plus $52.00 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. This section does not apply to inmates housed at an Arizona Department of Corrections facility that participates in electronic filing. 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 $402 filing and administrative fees or the application to proceed in forma pauperis to: 1 Revised 12/1/20 Phoenix & Prescott Divisions: U.S. District Court Clerk U.S. Courthouse, Suite 130 401 West Washington Street, SPC 10 Phoenix, Arizona 85003-2119 OR 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. This section does not apply to inmates housed at an Arizona Department of Corrections facility that participates in electronic filing. 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 within 21 days after serving it or within 21 days after any defendant has filed an answer, whichever is earlier. See Fed. R. Civ. P. 15(a). Thereafter, you must file a motion for leave to amend and lodge (submit) a proposed amended complaint. LRCiv 15.1. In addition, an amended complaint may not incorporate by reference any part of your prior complaint. LRCiv 15.1(a)(2). Any allegations or defendants not included in the amended complaint are considered dismissed. All amended complaints are subject to screening under the Prison Litigation Reform Act; screening your amendment will take additional processing time. 10. Exhibits. You should not submit exhibits with the complaint or amended complaint. Instead, the relevant information should be paraphrased. You should keep the exhibits to use to support or oppose a motion to dismiss, a motion for summary judgment, or at trial. 11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff of any judge. The only appropriate way to communicate with the Court is by filing a written pleading or motion. 2 12. Completing the Civil Rights Complaint Form. HEADING: 1. Your Name. Print your name, prison or inmate number, and institutional mailing address on the lines provided. 2. Defendants. If there are four or fewer defendants, print the name of each. If you name more than four defendants, print the name of the first defendant on the first line, write the words “and others” on the second line, and attach an additional page listing the names of all of the defendants. Insert the additional page after page 1 and number it “1A” at the bottom. 3. Jury Demand. If you want a jury trial, you must write “JURY TRIAL DEMANDED” in the space below “CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do so may result in the loss of the right to a jury trial. A jury trial is not available if you are seeking only injunctive relief. Part A. JURISDICTION: 1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. ' 1983 for state, county, or city defendants; “Bivens v. Six Unknown Federal Narcotics Agents” for federal defendants; or “other.” If you mark “other,” identify the source of that authority. 2. Location. Identify the institution and city where the alleged violation of your rights occurred. 3. Defendants. Print all of the requested information about each of the defendants in the spaces provided. If you are naming more than four defendants, you must provide the necessary information about each additional defendant on separate pages labeled “2-A,” “2-B,” etc., at the bottom. Insert the additional page(s) immediately behind page 2. Part B. PREVIOUS LAWSUITS: You must identify any other lawsuit you have filed in either state or federal court while you were a prisoner. Print all of the requested information about each lawsuit in the spaces provided. If you have filed more than three lawsuits, you must provide the necessary information about each additional lawsuit on a separate page. Label the page(s) as “2-A,” “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, CASE NO. __________________________________ (To be supplied by the Clerk) v. (1) _______________________________________ , (Full Name of Defendant) CIVIL RIGHTS COMPLAINT BY A PRISONER (2) _______________________________________ , (3) _______________________________________ , G Original Complaint G First Amended Complaint G Second Amended Complaint (4) _______________________________________ , Defendant(s). G Check if there are additional Defendants and attach page 1-A listing them. 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 12/1/20 1 550/555 B. DEFENDANTS 1. Name of first Defendant: . The first Defendant is employed as: ______________________________________________ at_______________________________________. (Position and Title) (Institution) 2. Name of second Defendant: . The second Defendant is employed as: as: ______________________________________________ at_______________________________________. (Position and Title) (Institution) 3. Name of third Defendant: . The third Defendant is employed as: ______________________________________________ at_______________________________________. (Position and Title) (Institution) 4. Name of fourth Defendant: . The fourth Defendant is employed as: ______________________________________________ at_______________________________________. (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: 1. Parties: v. 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 institution? 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? 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 institution? G Yes G No 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

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