SMITH v. WARDEN

Filing 4

ENTRY DIRECTING FURTHER PROCEEDINGS - The Clerk shall include a form complaint with Smith's copy of this Entry. Smith shall have through August 22, 2017, to file a complaint and if he files a complaint, he must also pay the $400. 00 filing fee or demonstrate his inability to do so. The motion regarding letter, dkt. 3 , is granted to the extent that the Clerk shall include a copy of the docket with Smith's copy of this Entry. The docket reflects all activity in this case (SEE ENTRY). Copy of Entry, form complaint and docket sheet sent to Plaintiff via US Mail. Signed by Judge Larry J. McKinney on 7/28/2017. (Attachments: # 1 form complaint, # 2 copy of docket sheet) (DW)

COMPLAINT FORM

(for filers who are prisoners without lawyers)
IN THE UNITED STATES DISTRICT COURT
FOR THE _________________ DISTRICT OF ______________________

(Full name of plaintiff(s))

vs

Case Number:

(Full name of defendant(s))

A.

(to be supplied by clerk of court)

PARTIES
1.

Plaintiff is a citizen of

, and is located at
(State)

____________________________________________________________________
(Address of prison or jail)
(If more than one plaintiff is filing, use another piece of paper).
2.

Defendant

__________________________________
(Name)

Complaint - 1

is (if a person or private corporation) a citizen of __________________________________
(State, if known)
and (if a person) resides at
__________
(Address, if known)
and (if the defendant harmed you while doing the defendant’s job)
worked for ___________________________________________________________________
(Employer’s name and address, if known)
(If you need to list more defendants, use another piece of paper.)
B.

STATEMENT OF CLAIM
On the space provided on the following pages, tell:
1.
Who violated your rights;
2.
What each defendant did;
3.
When they did it;
4.
Where it happened; and
5.
Why they did it, if you know.

Complaint - 2

Complaint - 3

C.

JURISDICTION

I am suing for a violation of federal law under 28 U.S.C. § 1331.
OR
I am suing under state law. The state citizenship of the plaintiff(s) is (are)
different from the state citizenship of every defendant, and the amount of
money at stake in this case (not counting interest and costs) is
$
_________.
D.

RELIEF WANTED
Describe what you want the court to do if you win your lawsuit. Examples may
include an award of money or an order telling defendants to do something or
stop doing something.

Complaint - 4

E.

JURY DEMAND

Jury Demand - I want a jury to hear my case
OR
Court Trial – I want a judge to hear my case

Dated this

day of

20_____.

Respectfully Submitted,

Signature of Plaintiff

Plaintiff’s Prisoner ID Number

(Mailing Address of Plaintiff)
(If more than one plaintiff, use another piece of paper).
REQUEST TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING THE
FILING FEE
I DO request that I be allowed to file this complaint without paying the filing
fee. I have completed a request to proceed in the district court without
prepaying the fee and attached it to the complaint.
I DO NOT request that I be allowed to file this complaint without prepaying the
filing fee under 28 U.S.C. § 1915, and I have included the full filing fee with this
complaint.

Complaint - 5