Smith v. Chapell et al

Filing 5

ORDER OF DISMISSAL WITH LEAVE TO AMEND. The complaint is DISMISSED with leave to amend. Within twenty-eight (28) days of the date this order is filed, Plaintiff shall file an amended complaint using the court's form complaint. The amended compla int must include the caption and civil case number used in this order and the words "AMENDED COMPLAINT" on the first page and write in the case number for this action, Case No. C 12-04859 EJD (PR). Plaintiff must answer all the questions on the form in order for the action to proceed. Failure to respond in accordance with this order by filing an amended complaint will result in the dismissal of this action without prejudice and without further notice to Plaintiff. The Clerk shall include two copies of the court's complaint with a copy of this order to Plaintiff. Signed by Judge Edward J. Davila on 12/6/2012. (Attachments: # 1 Form Habeas Complaint)(ecg, COURT STAFF) (Filed on 12/6/2012)

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COMPLAINT BY A PRISONER UNDER THE CIVIL RIGHTS ACT, 42 U.S.C §§ 1983
Name _________________________________________________________________
(Last)

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(First)

(Initial)

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Prisoner Number ________________________________________________________

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Institutional Address _____________________________________________________
_______________________________________________________________________
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UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA

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_____________________________________
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(Enter the full name o f plaintiff in this actio n.)

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vs.

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_____________________________________

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_____________________________________

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_____________________________________
(Enter the full name of the defendant(s) in this action)

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Case No. _____________________
(To be provided by the C lerk of C ourt)

COMPLAINT UNDER THE
CIVIL RIGHTS ACT,
Title 42 U.S.C § 1983

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[All questions on this complaint form must be answered in order for your action to proceed..]

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I.

Exhaustion of Administrative Remedies.

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[Note: You must exhaust your administrative remedies before your claim can go

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forward. The court will dismiss any unexhausted claims.]

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A.

Place of present confinement _______________________________

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B.

Is there a grievance procedure in this institution?

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YES ( )
C.

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Did you present the facts in your complaint for review through the grievance
procedure?

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NO ( )

YES ( )
D.

NO ( )

If your answer is YES, list the appeal number and the date and result of the

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appeal at each level of review. If you did not pursue a certain level of appeal,

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explain why.

COMPLAINT

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1. Informal appeal

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2. First formal level

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3. Second formal level

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4. Third formal level

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E.

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Is the last level to which you appealed the highest level of appeal available to
you?

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YES ( )

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F.

NO ( )

If you did not present your claim for review through the grievance procedure,

explain why.

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II.

Parties.
A.

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Write your name and your present address. Do the same for additional plaintiffs,
if any.

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B.

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Write the full name of each defendant, his or her official position, and his or her
place of employment.

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COMPLAINT

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III.

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Statement of Claim.
State here as briefly as possible the facts of your case. Be sure to describe how each

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defendant is involved and to include dates, when possible. Do not give any legal arguments or

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cite any cases or statutes. If you have more than one claim, each claim should be set forth in a

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separate numbered paragraph.

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IV.

Relief.
Your complaint cannot go forward unless you request specific relief. State briefly exactly

what you want the court to do for you. Make no legal arguments; cite no cases or statutes.

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COMPLAINT

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I declare under penalty of perjury that the foregoing is true and correct.

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Signed this ___________ day of ____________________, 20_____

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_____________________________________________

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(Plaintiff's signature)

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COMPLAINT

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