Burke v. St. Louis City Jails et al

Filing 27

MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that the Court's Order dated January 12, 2015, is VACATED. IT IS FURTHER ORDERED that plaintiff's motion to proceed in forma pauperis [ECF No. 2 ] is GRANTED. IT IS FURTHER ORDERED that the plain tiff must pay an initial filing fee of $1.00 within thirty (30) days of the date of this Order. Plaintiff is instructed to make his remittance payable to "Clerk, United States District Court," and to include upon it: (1) his name; ( 2) his prison registration number; (3) the case number; and (4) that the remittance is for an original proceeding. IT IS FURTHER ORDERED that the Clerk is directed to send plaintiff a prisoner civil rights complaint form. IT IS FURTHER ORDERED that plaintiff must complete the form and return it to the Court within thirty (30) days from the date of this Order. (Response to Court due by 7/31/2015.) Signed by District Judge Ronnie L. White on July 1, 2015. (Attachments: # 1 Prisoner Civil Rights Complaint Form)(BRP)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
DIVISION

(Enter above the full name of the
Plaintiff(s) in this action. Include prison
registration number(s).)
v.

(Enter above the full name of ALL Defendant(s) in this action. Fed. R. Civ. P. 10(a)
requires that the caption of the complaint
include the names of all the parties. Merely
listing one party and "et al." is insufficient.
Please attach additional sheets if necessary.

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Case No.
(To be assigned by Clerk)

PRISONER CIVIL RIGHTS COMPLAINT UNDER 42 U.S.C. § 1983
I.

PLACE OF PRESENT CONFINEMENT:

II.

PREVIOUS CIVIL ACTIONS:
A.

Have you brought any other civil actions in state or federal court dealing with the
same facts involved in this action or otherwise relating to your confinement?
YES

[

]

NO

[

]

B.

If your answer to “A” is YES, describe the action(s) in the space below. If there is
more than one action, you must describe the additional action(s) on a separate piece
of paper, using the same format as below.
1.

Parties to previous civil action:
Plaintiff(s):

Defendant(s):

2.
3.

Docket or case number:

4.

Name of Judge:

5.

Basic claim made:

6.

III.

Court where filed:

Present disposition (Is the case still pending? Is it closed? If closed, was it
appealed?):

GRIEVANCE PROCEDURES:
A.

Is there a prisoner grievance procedure at the institution in which you are
incarcerated?
YES

B.

[

]

NO

[

]

Have you presented this grievance system the facts which are at issue in this
complaint?
YES

[

]

NO

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[

]

C.

D.

IV.

If your answer to “B” is YES, what steps did you take:

If your answer to “B” is NO, explain why you have not used the grievance system:

PARTIES TO THIS ACTION:
A.

Plaintiff(s)
1.
2.

Plaintiff’s address:

3.

Registration number:

4.

B.

Name of Plaintiff:

Additional Plaintiff(s) and address(es):

Defendant(s)
1.

Name of Defendant:

2.

Defendant’s address:

3.

Defendant’s employer and job title:

4.

Additional Defendant(s) and address(es):

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V.

COUNSEL
A.

Do you have an attorney to represent you in this action?
YES

B.

[

]

NO

[

]

If your answer to “A” is NO, have you made an effort to contact an attorney to
represent you in this matter?
YES

[

]

NO

[

]

C.

If your answer to “B” is YES, state the name(s) and address(es) of the attorneys you
contacted and the results of those efforts:

D.

If your answer to “B” is NO, explain why you have not made such efforts:

E.

Have you previously been represented by counsel in a civil action in this Court?
YES

F.

[

]

NO

[

]

If your answer to “E” is YES, state the attorney’s name and address:

-4-

VI.

Statement of claim (State as briefly as possible the facts of your case. Describe how each
defendant is involved. You must state exactly what each defendant personally did, or failed
to do, which resulted in harm to you. Include also the names of other persons involved, dates,
and places. Be as specific as possible. State your claims in numbered paragraphs. You may
use additional paper if necessary):

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VII.

RELIEF
State briefly and exactly what you want the Court to do for you. Do not make legal
arguments. (Note: If you are a state prisoner and you seek from this Court relief that affects
the length or duration of your imprisonment, your case must be filed on a § 2254 form.)

VIII.

MONEY DAMAGES:
A) Do you claim either actual or punitive monetary damages for the acts alleged in this
complaint?
YES G

NO G

B) If your answer to "A" is YES, state below the amount claimed and the reason or reasons
you believe you are entitled to recover such money damages:

IX.

Do you claim that the wrongs alleged in the complaint are continuing to occur at the present
time?
YES

[

]

NO

Signature of attorney or pro se Plaintiff(s)

[

]

Date
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