Varnell v. Washington State Department of Corrections et al

Filing 5

ORDER TO SHOW CAUSE OR AMEND COMPLAINT on or before August 20, 2015, by Magistrate Judge David W. Christel. (Attachments: # 1 FORM- Amended Complaint, # 2 FORM- Address List of Defendants re Service) **12 PAGES, PRINT ALL** (GMR)

Revision Date: 4/8/2013

INSTRUCTIONS FOR PRISONERS SEEKING TO FILE
A CIVIL RIGHTS COMPLAINT PURSUANT TO 42 U.S.C. § 1983
You must comply with the following instructions before the Clerk will file your Complaint
Local Rule CR 103, Local Rules for the Western District of Washington, requires you to
submit your Complaint on the form furnished by the Court (a § 1983 form is attached). The clerk will
upload the complaint to the docket and make copies of it for service upon the defendant(s). Plaintiff
should keep a copy of the complaint for his or her own records; the clerk will not routinely return a
copy of the complaint to plaintiff.
You must submit either the full $400.00 filing fee or a completed in forma pauperis
application, including a certified copy of your prisoner account. Carefully read the information sheet
for prisoners seeking leave to proceed in forma pauperis (without prepayment of the entire filing
fee).
You may bring your Complaint to the United States District Court for the Western District of
Washington only if one or more of the named defendants is located within this district, or if your
claim arose from this district. If you have more than one claim, you must file a separate complaint
for each claim unless they are related to the same incident or issue.
Your Complaint must be legibly handwritten or typed. NOTE: DO NOT WRITE ON THE
BACK OF ANY OF THE PAGES OF THE COMPLAINT; any writing on the back of any page
might not be considered by the Court. You must sign the Complaint and declare under penalty of
perjury that the facts stated in the Complaint are correct. If you need additional space to answer a
question, you should attach an additional page.
You are required to state facts in support of each claim. The Complaint should refer to the
provision of the federal constitution or federal law on which you are relying. THE COMPLAINT
SHOULD NOT CONTAIN LEGAL ARGUMENTS OR CITATIONS.
You must keep the Clerk of the Court informed of any change of address. If you fail to do
so, the Clerk cannot be responsible for your failure to receive Court Orders. This also could result in
the dismissal of your suit.

If your claim arose in King, Snohomish, Skagit,
Whatcom or Island Counties, mail your completed
forms, the originals and all copies to:

If your claim arose in any other county in the
Western District of Washington, mail your
completed forms, the originals and all copies to:

Clerk, U.S. District Court
700 Stewart Street, Suite 2310
Seattle WA 98101-1271

Clerk, U.S. District Court
1717 Pacific Ave, Room 3100
Tacoma WA 98402

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UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WASHINGTON

____________________________________
Mitchell Lee Varnell
(Name of Plaintiff)

AMENDED
3:15-cv-05443-BHS-DWC
CIVIL RIGHTS COMPLAINT
BY A PRISONER UNDER 42
U.S.C. § 1983

vs.
____________________________________
____________________________________
____________________________________
____________________________________
(Names of Defendant(s))

I. Previous Lawsuits:
A. Have you brought any other lawsuits in any federal court in the United States while a
prisoner?:
Yes

No

B. If your answer to A is yes, how many?:_________________. Describe the lawsuit in the space
below. (If there is more than one lawsuit, describe the additional lawsuits on another piece of
paper using the same outline.)
1. Parties to this previous lawsuit:
Plaintiff:________________________________________________________________
_______________________________________________________________________
Defendants:______________________________________________________________
________________________________________________________________________
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2. Court (give name of District):_________________________________________________
3. Docket Number: ______________________________________________________________
4. Name of judge to whom case was assigned: _____________________________________
5. Disposition (For example: Was the case dismissed as frivolous or for failure to state a claim?
Was it appealed? Is it still pending?):
______________________________________________________________________________
6. Approximate date of filing lawsuit: _______________________________________________
7. Approximate date of disposition: _________________________________________________

II. Place of Present Confinement:________________________________________________________
A. Is there a prisoner grievance procedure available at this institution?

Yes

No

B. Have you filed any grievances concerning the facts relating to this complaint?
Yes

No

If your answer is NO, explain why not:
______________________________________________________________________________
______________________________________________________________________________
C. Is the grievance process completed?

Yes

No

If your answer is YES, ATTACH A COPY OF THE FINAL GRIEVANCE
RESOLUTION for any grievance concerning facts relating to this case.

III. Parties to this Complaint
A. Name of Plaintiff: __________________________________ Inmate No.: ________________
Address: ______________________________________________________________________
(In Item B below, place the full name of the defendant, his/her official position, and his/her place
of employment. Use item C for the names, positions and places of employment of any additional
defendants. Attach additional sheets if necessary.)
B. Defendant: ___________________________________ Official Position: ________________
Place of employment: ____________________________________________________________

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C. Additional defendants__________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

IV. Statement of Claim
(State here as briefly as possible the facts of your case. Describe how each defendant is involved,
including dates, places, and other persons involved. Do not give any legal arguments or cite any
cases or statutes. If you allege a number of related claims, number and set forth each claim in a
separate paragraph. Attach additional sheets if necessary.)
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V. Relief
(State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no
cases or statutes.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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_____________________________________________________________________________________
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_____________________________________________________________________________________
_____________________________________________________________________________________

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

Signed this ________ day of ___________________ 20 ______.

_____________________________________________
(Signature of Plaintiff)

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