In Re: Kenneth Erickson

Filing 17

ORDER denying ECF No. 1 IFP application; directing Clerk to send Plaintiff IFP form and instructions (attached hereto for transmittal to P); giving Plaintiff 30 days to file fully complete IFP application or pay full $400 filing fee; directing Plaintiff to submit a complaint within 30 days; directing Clerk to send Plaintiff 1983 form and instructions (attached hereto for transmittal to P); denying without prejudice ECF Nos. 4 , 6 Motions. Signed by Magistrate Judge Valerie P. Cooke on 7/12/2017. (Attachments: # 1 IFP Form, # 2 IFP Instructions, # 3 1983 Form, # 4 1983 Form Instructions) (Copies have been distributed pursuant to the NEF - KR)

Name

Prison Number
UNITED STATES DISTRICT COURT
DISTRICT OF NEVADA
,
Plaintiff,

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vs.
,
,
,
,
,
Defendant(s).

CASE NO.
(To be supplied by the Clerk)
CIVIL RIGHTS COMPLAINT
PURSUANT TO
42 U.S.C. § 1983

A. JURISDICTION
1)

,

This complaint alleges that the civil rights of Plaintiff,
(Print Plaintiff’s name)
who presently resides at

, were

violated by the actions of the below named individuals which were directed against
Plaintiff at

on the following dates
(institution/city where violation occurred)
,

(Count I)

Revised 10-7-16

, and
(Count II)

.
(Count III)

Make a copy of this page to provide the below
information if you are naming more than five (5) defendants
2) Defendant

resides at
,
(full name of first defendant)
(address if first defendant)
. This defendant is sued in his/her
and is employed as
(defendant’s position and title, if any)
individual
official capacity. (Check one or both). Explain how this defendant was
acting
under color of law:

3) Defendant

resides at

,

(full name of first defendant)
(address if first defendant)
and is employed as
. This defendant is sued in his/her
(defendant’s position and title, if any)
individual
official capacity. (Check one or both). Explain how this defendant was
acting
under color of law:
4) Defendant

resides at

,

(full name of first defendant)
(address if first defendant)
and is employed as
. This defendant is sued in his/her
(defendant’s position and title, if any)
individual
official capacity. (Check one or both). Explain how this defendant was
acting
under color of law:

5) Defendant

resides at
,
(full name of first defendant)
(address if first defendant)
. This defendant is sued in his/her
and is employed as
(defendant’s position and title, if any)
individual
official capacity. (Check one or both). Explain how this defendant was
acting
under color of law:

2

6) Defendant

resides at

,

(full name of first defendant)
(address if first defendant)
and is employed as
. This defendant is sued in his/her
(defendant’s position and title, if any)
individual
official capacity. (Check one or both). Explain how this defendant was
acting
under color of law:

7) Jurisdiction is invoked pursuant to 28 U.S.C. § 1343 (a)(3) and 42 U.S.C. § 1983. If you wish
to assert jurisdiction under different or additional statutes, list them below.

------------------------------

1)

B. NATURE OF THE CASE
Briefly state the background of your case.

----------------------------C. CAUSE OF ACTION
3

COUNT I
The following civil rights has been violated:

Supporting Facts: [Include all fact you consider important. State the facts clearly,
in your own words, and without citing legal authority or argument. Be sure you
describe exactly what each specific defendant (by name) did to violate your rights].

4

COUNT II
The following civil rights has been violated:

Supporting Facts: [Include all fact you consider important. State the facts clearly,
in your own words, and without citing legal authority or argument. Be sure you
describe exactly what each specific defendant (by name) did to violate your rights].

5

COUNT III
The following civil rights has been violated:

Supporting Facts: [Include all fact you consider important. State the facts clearly,
in your own words, and without citing legal authority or argument. Be sure you
describe exactly what each specific defendant (by name) did to violate your rights].

---------------------------------D. PREVIOUS LAWSUITS AND ADMINISTRATIVE RELIEF
1)

Have you filed other actions in state or federal courts involving the same or similar facts
as involved in this action?
Yes
No. If your answer is “Yes”, describe each
lawsuit. (If more than one, describe the others on an additional page following the below
6

outline).
a)
b)

Name of court and docket number:

c)

Disposition (for example, was the case dismissed , appealed or is it still pending?):

d)

Issues raised:

e)

Approximate date it was filed:

f)
2)

Defendants:

Approximate date of disposition:

Have you filed an action in federal court that was dismissed because it was determined to
be frivolous, malicious, or failed to state a claim upon which relief could be granted?
Yes

No. If your answer is “Yes”, describe each lawsuit. (If you had more than

three actions dismissed based on the above reasons, describe the others on an additional page
following the below outline.)
Lawsuit #1 dismissed as frivolous, malicious, or failed to state a claim:
a)

Defendants:

.

b)

Name of court and case number:

.

c)

The case was dismissed because it was found to be (check one):
malicious or

frivolous

failed to state a claim upon which relief could be granted.

d)

Issues raised:

e)

Approximate date it was filed:

f)

Approximate date of disposition:

Lawsuit #2 dismissed as frivolous, malicious, or failed to state a claim:
a)

Defendants:

.

b)

Name of court and case number:

.

7

c)

The case was dismissed because it was found to be (check one):
malicious or

frivolous

failed to state a claim upon which relief could be granted.

d)

Issues raised:

e)

Approximate date it was filed:

f)

Approximate date of disposition:

Lawsuit #3 dismissed as frivolous, malicious, or failed to state a claim:
a)

Defendants:

.

b)

Name of court and case number:

.

c)

The case was dismissed because it was found to be (check one):
malicious or

failed to state a claim upon which relief could be granted.

d)

Issues raised:

e)

Approximate date it was filed:

f)

3)

frivolous

Approximate date of disposition:

Have you attempted to resolve the dispute stated in this action by seeking relief from the
proper administrative officials, e.g., have you exhausted available administrative grievance
procedures?

Yes

No. If your answer is “No”, did you not attempt administrative

relief because the dispute involved the validity of a: (1)
state or federal court decision; (3)
board decision; or (5)

disciplinary hearing; (2)

state or federal law or regulation; (4)

other

parole
.

If your answer is “Yes”, provide the following information. Grievance Number

.

Date and institution where grievance was filed

.

Response to grievance:

8

------------------E. REQUEST FOR RELIEF
I believe that I am entitled to the following relief:

I understand that a false statement or answer to any question in this complaint will
subject me to penalties of perjury. I DECLARE UNDER PENALTY OF PERJURY
UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT THE
FOREGOING IS TRUE AND CORRECT. See 28 U.S.C. § 1746 and 18 U.S.C. § 1621.

(Name of Person who prepared or helped
prepare this complaint if not Plaintiff)

(Signature of Plaintiff)

(Date)
---------------------------(Additional space if needed; identify what is being continued)

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