Teen v. Poland

Filing 7

MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that plaintiff's motion to proceed in forma pauperis [ECF No. 6 ] is GRANTED. IT IS FURTHER ORDERED that the plaintiff must pay an initial filing fee of $23.00 within twenty-one (21) days of t he 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 remit tance is for an original proceeding. IT IS FURTHER ORDERED that the Clerk is directed to send plaintiff a prisoner civil rights complaint. IT IS FURTHER ORDERED that plaintiff must use the form and file an amended complaint within twenty-one (21) d ays of the date of this Order. IT IS FURTHER ORDERED that if plaintiff does not comply with this Order, the Court will dismiss this action without further proceedings. Signed by District Judge Ronnie L. White on July 10, 2017. (Attachments: # 1 Civil Rights Complaint)(BRP)

Reset

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
DIVISION

(Enter above the full name of the Plaintiff[s]
in this action.)

- vs -

(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
of District Court)

COMPLAINT
I.

State the grounds for filing this case is Federal Court (include federal statutes and/or U.S.
Constitutional provisions, if you know them):

II.

Plaintiff,

resides at
,

,

street address

city

,
state

,
zip code

,
county

.
telephone number

(if more than one plaintiff, provide the same information for each plaintiff below)

III.

Defendant,

lives at, or its business is located at
,

,

street address

city
,

state

,
county

.
zip code

(if more than one defendant, provide the same information for each defendant below)

2

IV.

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. You may use additional paper
if necessary):

3

V.

Relief: State briefly and exactly what you want the Court to do for you.

VI.

MONEY DAMAGES:
A)

Do you claim either actual or punitive monetary damages for the acts alleged in
this complaint?
YES

B)

VII.

NO

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:

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

NO

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

day of

, 20

Signature of Plaintiff(s)
4