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)

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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

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