De Rego v. Hernandez et al
Filing
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ORDER: Plaintiff's Application to Proceed In Forma Pauperis (Doc. 2 ) is granted. As required by the accompanying Order to the appropriate government agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial fili ng fee of $23.33. The Complaint (Doc. 1 ) is dismissed for failure to state a claim. Plaintiff has 30 days from the date this Order is filed to file a first amended complaint in compliance with this Order. If Plaintiff fails to file an amended complaint within 30 days, the Clerk of Court must, without further notice, enter a judgment of dismissal of this action with prejudice that states that the dismissal may count as a "strike" under 28 U.S.C. § 1915(g) 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 James A Teilborg on 1/27/2025. (KJ)
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IN THE UNITED STATES DISTRICT COURT
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FOR THE DISTRICT OF ARIZONA
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Kilani De Rego,
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No.
CV-24-02754-PHX-JAT (ESW)
Plaintiff,
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v.
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Tiana Hernandez, et al.,
ORDER
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Defendants.
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Plaintiff Kilani De Rego, who is confined in the Saguaro Correctional Center, has
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filed a pro se civil rights Complaint pursuant to 42 U.S.C. § 1983 (Doc. 1) and an
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Application to Proceed In Forma Pauperis (Doc. 2). The Court will dismiss the Complaint
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with leave to amend.
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I.
Application to Proceed In Forma Pauperis and Filing Fee
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The Court will grant Plaintiff’s Application to Proceed In Forma Pauperis. 28
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U.S.C. § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C.
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§ 1915(b)(1). The Court will assess an initial partial filing fee of $23.33. The remainder
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of the fee will be collected monthly in payments of 20% of the previous month’s income
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credited to Plaintiff’s trust account each time the amount in the account exceeds $10.00.
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28 U.S.C. § 1915(b)(2). The Court will enter a separate Order requiring the appropriate
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government agency to collect and forward the fees according to the statutory formula.
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....
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II.
Statutory Screening
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The Court is required to screen complaints brought by prisoners seeking relief
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against a governmental entity or an officer or an employee of a governmental entity. 28
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U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff
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has raised claims that are legally frivolous or malicious, that fail to state a claim upon which
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relief may be granted, or that seek monetary relief from a defendant who is immune from
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such relief. 28 U.S.C. § 1915A(b)(1)–(2). Complaints filed in forma pauperis are also
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subject to screening. 28 U.S.C. 1915(e)(2) (in a case in which a plaintiff has been granted
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in forma pauperis status, the court “shall dismiss the case at any time if the court determines
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that . . . (B) the action . . . (i) is frivolous or malicious; (ii) fails to state a claim on which
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relief may be granted; or (iii) seeks monetary relief against a defendant who is immune
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from such relief”).
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A pleading must contain a “short and plain statement of the claim showing that the
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pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 does
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not demand detailed factual allegations, “it demands more than an unadorned, the-
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defendant-unlawfully-harmed-me accusation.”
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(2009). “Threadbare recitals of the elements of a cause of action, supported by mere
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conclusory statements, do not suffice.” Id.
Ashcroft v. Iqbal, 556 U.S. 662, 678
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“[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a
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claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly,
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550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual content
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that allows the court to draw the reasonable inference that the defendant is liable for the
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misconduct alleged.” Id. “Determining whether a complaint states a plausible claim for
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relief [is] . . . a context-specific task that requires the reviewing court to draw on its judicial
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experience and common sense.” Id. at 679. Thus, although a plaintiff’s specific factual
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allegations may be consistent with a constitutional claim, a court must assess whether there
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are other “more likely explanations” for a defendant’s conduct. Id. at 681.
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But as the United States Court of Appeals for the Ninth Circuit has instructed, courts
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must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 342
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(9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less stringent
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standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. Pardus, 551
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U.S. 89, 94 (2007) (per curiam)).
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If the Court determines that a pleading could be cured by the allegation of other
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facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal
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of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) (en banc). The
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Court will dismiss Plaintiff’s Complaint for failure to state a claim, but because it may
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possibly be amended to state a claim, the Court will dismiss it with leave to amend.
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III.
Complaint
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In his three-count Complaint, Plaintiff asserts claims for First Amendment
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retaliation. Plaintiff names Unit Manager Tiani Hernandez, Correctional Officer Billy
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Montoya, Case Manager Cameille Susunkewa, Health Services Administrator Crystal
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Shanley, and Investigator Michael Gawlik as Defendants. Plaintiff is seeking injunctive
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relief and money damages.
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Plaintiff alleges that on June 27, 2024, Defendant Montoya took Plaintiff’s medical
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sunglasses from his cell and, when Plaintiff told Montoya he was going to file a grievance
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against him, gave the sunglasses to Defendant Susunkewa in retaliation for Plaintiff’s use
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of the grievance process. Later that day, Plaintiff told Defendant Hernandez he was going
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to file a grievance against Montoya and Susunkewa, prompting Defendants Hernandez,
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Susunkewa, and Shanley to destroy the sunglasses the following day as retaliation for
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Plaintiff’s use of the grievance process. On July 7, 2024, Plaintiff filed a grievance against
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Hernandez based on the confiscation and destruction of his medical sunglasses.
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Defendants Hernandez, Susunkewa, and Gawlik then placed Plaintiff on lockdown for 23
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hours as punishment for filing grievances. Plaintiff asserts a retaliation claim against
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Defendants Montoya and Susunkewa in Count One; Defendants Hernandez, Susunkewa,
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and Shanley in Count Two; and Defendants Hernandez, Susunkewa, and Gawlik in Count
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Three.
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IV.
Failure to State a Claim
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To prevail in a § 1983 claim, a plaintiff must show that (1) acts by the defendants
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(2) under color of state law (3) deprived him of federal rights, privileges or immunities and
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(4) caused him damage. Thornton v. City of St. Helens, 425 F.3d 1158, 1163-64 (9th Cir.
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2005) (quoting Shoshone-Bannock Tribes v. Idaho Fish & Game Comm’n, 42 F.3d 1278,
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1284 (9th Cir. 1994)). In addition, a plaintiff must allege that he suffered a specific injury
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as a result of the conduct of a particular defendant and he must allege an affirmative link
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between the injury and the conduct of that defendant. Rizzo v. Goode, 423 U.S. 362, 371-
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72, 377 (1976).
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Although pro se pleadings are liberally construed, Haines v. Kerner, 404 U.S. 519,
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520-21 (1972), conclusory and vague allegations will not support a cause of action. Ivey
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v. Bd. of Regents, 673 F.2d 266, 268 (9th Cir. 1982). Further, a liberal interpretation of a
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civil rights complaint may not supply essential elements of the claim that were not initially
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pled. Id.
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A viable claim of First Amendment retaliation contains five basic elements: (1) an
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assertion that a state actor took some adverse action against an inmate (2) because of
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(3) that prisoner’s protected conduct, and that such action (4) chilled the inmate’s exercise
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of his First Amendment rights (or that the inmate suffered more than minimal harm) and
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(5) did not reasonably advance a legitimate correctional goal. Rhodes v. Robinson, 408
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F.3d 559, 567-68 (9th Cir. 2005); see also Hines v. Gomez, 108 F.3d 265, 267 (9th Cir.
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1997) (retaliation claim requires an inmate to show (1) that the prison official acted in
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retaliation for the exercise of a constitutionally protected right, and (2) that the action
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“advanced no legitimate penological interest”).
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demonstrating that his exercise of his First Amendment rights was a substantial or
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motivating factor behind the defendants’ conduct. Mt. Healthy City Sch. Dist. Bd. of Educ.
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The plaintiff has the burden of
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v. Doyle, 429 U.S. 274, 287 (1977); Soranno’s Gasco, Inc. v. Morgan, 874 F.2d 1310, 1314
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(9th Cir. 1989).
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Plaintiff’s allegations are too vague and conclusory to state a claim under the
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foregoing standard. Although Plaintiff claims that Defendants’ conduct was retaliatory, he
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has not alleged any underlying facts to support this assertion, and his allegations
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concerning his lockdown and the confiscation and destruction of his medical sunglasses
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are not specific enough to support a reasonable inference that such conduct failed to
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reasonably advance a legitimate correctional goal. Moreover, to the extent Plaintiff’s
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allegations are directed against a group of Defendants collectively, without any factual
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specificity as to what any particular Defendant did or failed to do, they are insufficient to
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state a claim. See Marcilis v. Twp. of Redford, 693 F.3d 589, 596 (6th Cir. 2012) (upholding
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dismissal of Bivens complaint that referred to all defendants “generally and categorically”
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because the plaintiff had failed to “‘allege, with particularity, facts that demonstrate what
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each defendant did to violate the asserted constitutional right.’” (quoting Lanman v.
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Hinson, 529 F.3d 673, 684 (6th Cir. 2008))); see also Sebastian Brown Prods., LLC v.
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Muzooka, Inc., 143 F. Supp. 3d 1026, 1037 (N.D. Cal. 2014) (“A plaintiff ‘must identify
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what action each Defendant took that caused Plaintiffs’ harm, without resort to generalized
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allegations against Defendants as a whole.”); Flores v. EMC Mortg. Co., 997 F. Supp. 2d
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1088, 1103 (N.D. Cal. 2014) (complaint failed to satisfy Rule 8 where it lacked “facts of
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defendants’ specific wrongdoing to provide fair notice as to what each defendant is to
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defend”); Gauvin v. Trombatore, 682 F. Supp. 1067, 1071 (N.D. Cal. 1988) (holding that
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plaintiff who “lumped together [all defendants] in a single, broad allegation” had failed to
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state a claim). Plaintiff has therefore failed to state a claim under the First Amendment,
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and the Complaint will be dismissed with leave to amend.
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V.
Leave to Amend
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For the foregoing reasons, the Court will dismiss Plaintiff’s Complaint for failure to
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state a claim upon which relief may be granted. Within 30 days, Plaintiff may submit a
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first amended complaint to cure the deficiencies outlined above. The Clerk of Court will
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mail Plaintiff a court-approved form to use for filing a first amended complaint. If Plaintiff
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fails to use the court-approved form, the Court may strike the amended complaint and
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dismiss this action without further notice to Plaintiff.
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Plaintiff must clearly designate on the face of the document that it is the “First
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Amended Complaint.” The first 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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A first 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 F.2d
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1542, 1546 (9th Cir. 1990). After amendment, the Court will treat the original Complaint
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as nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised in the
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original Complaint and that was voluntarily dismissed or was dismissed without prejudice
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is waived if it is not alleged in a first amended complaint. Lacey v. Maricopa County, 693
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F.3d 896, 928 (9th Cir. 2012) (en banc).
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If Plaintiff files an amended complaint, Plaintiff must write short, plain statements
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telling the Court: (1) the constitutional right Plaintiff believes was violated; (2) the name
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of the Defendant who violated the right; (3) exactly what that Defendant did or failed to
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do; (4) how the action or inaction of that Defendant is connected to the violation of
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Plaintiff’s constitutional right; and (5) what specific injury Plaintiff suffered because of
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that Defendant’s conduct. See Rizzo, 423 U.S. at 371-72, 377.
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Plaintiff must repeat this process for each person he names as a Defendant. If
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Plaintiff fails to affirmatively link the conduct of each named Defendant with the specific
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injury suffered by Plaintiff, the allegations against that Defendant will be dismissed for
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failure to state a claim.
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Defendants has violated a constitutional right are not acceptable and will be
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dismissed.
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Conclusory allegations that a Defendant or group of
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VI.
Warnings
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A.
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If Plaintiff is released while this case remains pending, and the filing fee has not
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been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court
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that he intends to pay the unpaid balance of his filing fee within 120 days of his release or
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(2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may
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result in dismissal of this action.
Release
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B.
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Plaintiff must file and serve a notice of a change of address in accordance with Rule
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83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion for other
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relief with a notice of change of address. Failure to comply may result in dismissal of this
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action.
Address Changes
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C.
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If Plaintiff fails to timely comply with every provision of this Order, including these
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warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d
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at 1260-61 (a district court may dismiss an action for failure to comply with any order of
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the Court).
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IT IS ORDERED:
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(1)
Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 2) is granted.
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(2)
As required by the accompanying Order to the appropriate government
Possible Dismissal
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agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing fee
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of $23.33.
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(3)
The Complaint (Doc. 1) is dismissed for failure to state a claim. Plaintiff
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has 30 days from the date this Order is filed to file a first amended complaint in compliance
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with this Order.
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(4)
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If Plaintiff fails to file an amended complaint within 30 days, the Clerk of
Court must, without further notice, enter a judgment of dismissal of this action with
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prejudice that states that the dismissal may count as a “strike” under 28 U.S.C. § 1915(g)
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and deny any pending unrelated motions as moot.
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(5)
The Clerk of Court must mail Plaintiff a court-approved form for filing a civil
rights complaint by a prisoner.
Dated this 27th day of January, 2025.
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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 $405.00 ($350.00 filing
fee plus $55.00 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. Unless you are an inmate housed at an Arizona Department of Corrections facility
that participates in electronic filing, mail the original and one copy of the complaint with the
$405 filing and administrative fees or the application to proceed in forma pauperis to:
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Revised 11/6/24
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.
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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,” “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.
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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,
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 12/1/23
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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.
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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 at
your institution?
G Yes
G No
G Yes
G No
b. Did you submit a request for administrative relief on Count I?
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:
.
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
G Yes
G No
b. Did you submit a request for administrative relief on Count II?
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
G Yes
G No
b. Did you submit a request for administrative relief on Count III?
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.
6
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