Filing 4

ENTRY Dismissing Petition for Writ of Habeas Corpus - This action is dismissed without prejudice and Judgment consistent with this Entry shall now issue. The clerk is directed to include a copy of a prisoner civil rights complaint form along with the plaintiff's copy of this Entry. Judgment consistent with this Entry shall now issue (SEE ENTRY). Copy sent to Petitioner via US Mail. Signed by Judge Jane Magnus-Stinson on 8/9/2017. (Attachments: # 1 copy of a prisoner civil rights complaint form)(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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