Snowden v. Rankin

Full title: Camille Anjanette Snowden, Plaintiff, v. Linda Rankin, et al., Defendants

Court: United States District Court, D. Arizona

Date published: Feb 20, 2008

No. CV 07-1992-PHX-SMM (HCE) (D. Ariz. Feb. 20, 2008)

Opinion

No. CV 07-1992-PHX-SMM (HCE).

February 20, 2008

ORDER

STEPHEN McNAMEE, Chief District Judge

On October 15, 2007, Plaintiff Camille Anjanette Snowden, who was confined in Estrella Jail in Phoenix, Arizona, filed a pro se civil rights Complaint pursuant to 42 U.S.C. § 1983, an Application to Proceed In Forma Pauperis, and an Amended Complaint. (Doc.# 1, 3.)¹ The same day, a Notice of Assignment was issued to Plaintiff and sent to her address of record. (Doc.# 2.) On October 25, 2007, a copy of the Notice of Assignment mailed to Plaintiff was returned to the Court indicating that Plaintiff had been released. (Doc.# 4.) Further, on November 28, 2007, Plaintiff filed a letter in which she indicated that she had been released by providing two alternative out-of-state addresses for mail from the Court to be sent to her. (Doc.# 5.) On December 27, 2007, the Court gave Plaintiff 30 days within which to pay the $350.00 filing fee or to show cause why she was unable to pay the filing fee. (Doc.# 7.) On January 3, 2008, Plaintiff filed another Application to Proceed In Forma Pauperis wherein which she clarifies that she remains in custody. The Court will grant Plaintiff leave to proceed without prepayment in full of the $350.00 filing fee and order that the docket be updated to reflect her current Jail address. The Court will dismiss the Complaint with leave to amend.

1 "Doc.#" refers to the docket number of documents filed in this action.

I. Application to Proceed In Forma Pauperis and Filing Fee

Plaintiff's Application to Proceed In Forma Pauperis will be granted. 28 U.S.C. § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. § 1915(b)(1). The Court will assess an initial partial filing fee of $7.17. The remainder of the fee will be collected monthly in payments of 20% of the previous month's income each time the amount in the account exceeds $10.00. 28 U.S.C. § 1915(b)(2). The Court will enter a separate Order requiring the appropriate government agency to collect and forward the fees according to the statutory formula.

II. Statutory Screening of Prisoner Complaints

III. Complaint

28 U.S.C. § 1915A28 U.S.C. § 1915Apro se See Lopez v. Smith 203 F.3d 11221127-29 en banc Pliler v. Ford542 U.S. 225231see also Lopez203 F.3d at 1131

IV. Failure to State a Claim

To state a claim under § 1983, a plaintiff must allege facts supporting that (1) the conduct about which she complains was committed by a person acting under the color of state law and (2) the conduct deprived her of a federal constitutional or statutory right. Wood v. Ostrander, 879 F.2d 583, 587 (9th Cir. 1989). In addition, a plaintiff must allege that she suffered a specific injury as a result of the conduct of a particular defendant and she must allege an affirmative link between the injury and the conduct of that defendant. Rizzo v. Goode, 423 U.S. 362, 371-72, 377 (1976).

A. Moore, Mitchell, and Lawson

Plaintiff filed claims against Sergeant Moore, Officer Mitchell, and Arizona Assistant Attorney General Lawson. She fails, however, to allege any facts connecting any of these Defendants to any alleged violation of her federal constitutional or statutory rights. For that reason, she fails to state a claim against any of them. Further, to the extent that Plaintiff files an amended complaint including claim(s) against Lawson, she is informed that a plaintiff cannot maintain a suit against an individual prosecutor under § 1983 for conduct that is "intimately associated" with the judicial phase of the criminal process because prosecutors are entitled to absolute immunity from suit in such circumstances. Burns v. Reed, 500 U.S. 478, 486 (1991) (quoting Imbler v. Pachtman, 424 U.S. 409, 430 (1976);accord Botello v. Gammick, 413 F.3d 971, 975 (9th Cir. 2005).

B. Davis, Farney, and Prato

Plaintiff names Davis, Farney, and Prato as Defendants and seeks relief pursuant to § 1983 in connection with their representation of her in state criminal proceedings, which Plaintiff alleges violated her state constitutional rights. Plaintiff's claims against these Defendants fail for at least two reasons. First, Plaintiff fails to allege any violation of her federal constitutional or statutory rights. Second, even if Plaintiff had alleged a federal constitutional or statutory violation against these Defendants, the actions of defense counsel are not taken under color of state law. To state a § 1983 claim, a plaintiff must allege that a "defendant's actions were taken under color of state law." Gritchen v. Collier, 254 F.3d 807, 812 (9th Cir. 2001) (citing Flagg Bros., Inc. v. Brooks, 436 U.S. 149, 155-56 (1978)). "Acting under color of state law is 'a jurisdictional requisite for a § 1983 action.'" Id. (quoting West v. Atkins, 487 U.S. 42, 46 (1988)). "[A] person acts under color of state law only when exercising power 'possessed by virtue of state law and made possible only because the wrongdoer is clothed with the authority of state law.'" Polk County v. Dodson, 454 U.S. 312, 317-18 (1981) (quoting United States v. Classic, 313 U.S. 299, 326 (1941)). Whether an attorney representing a criminal defendant is privately retained, a public defender or court-appointed counsel, the attorney does not act under color of state law.² See Polk County, 454 U.S. at 317-18; Miranda v. Clark County, Nevada, 319 F.3d 465, 468 (9th Cir. 2003) ( en banc). For these reasons, Plaintiff fails to state a claim against these Defendants and they will be dismissed.

2 To the extent that this claim is predicated on these Defendants' position as supervisors or administrators, Plaintiff also fails to state a claim. Liability under § 1983 may not be predicated upon respondeat superior. Monell v. Dep't of Soc. Servs., 436 U.S. 658 (1978); Taylor v. List, 880 F.2d 1040, 1045 (9th Cir. 1989).

C. Medical Care

In Count II, Plaintiff alleges a denial of medical care against Nurse Rankin. To state a claim for a constitutional violation regarding medical care, a plaintiff must allege facts to support that she has or had a serious medical need and that a particular defendant acted with deliberate indifference to that need. See Estelle v. Gamble, 429 U.S. 97, 104-05 (1976) (Eighth Amendment standard for convicted inmates); Lolli v. County of Orange, 351 F.3d 410, 418-19 (9th Cir. 2003) (Fourteenth Amendment standard for pretrial detainees). To allege a serious medical need, a plaintiff must set forth facts to support that the "'failure to treat a prisoner's condition could result in further significant injury or the 'unnecessary and wanton infliction of pain.'" Jett v. Penner, 439 F.3d 1091, 1096 (9th Cir. 2006) (quoting McGuckin v. Smith, 974 F.2d 1050, 1059 (9th Cir. 1991), overruled on other grounds by WMX Techs, Inc. v. Miller, 104 F.3d 1133 (9th Cir. 1997) ( en banc)). Deliberate indifference may occur if "prison officials deny, delay or intentionally interfere with medical treatment." Hutchinson v. United States, 838 F.2d 390, 394 (9th Cir. 1988). Mere negligence, however, "in diagnosing or treating a medical condition, without more, does not violate a prisoner's Eighth Amendment rights.'" Lopez, 203 F.3d at 1132 (quoting Hutchinson, 838 F.2d at 394). Further, a delay in receiving medical care, without more, is insufficient to state a claim against a jailor for deliberate indifference unless the plaintiff can show that the delay in treatment harmed her. Shapley v. Nevada Bd. of State Prison Comm'rs, 766 F.2d 404, 407 (9th Cir. 1985).

Plaintiff alleges that Nurse Rankin "documented" that Plaintiff had a urine test that showed no "medical problems and charted false information" in Plaintiff's medical chart. Thus, Plaintiff seems to contend that Rankin falsified her medical records so that medical requests would be denied. She alleges that she was injured when a emergency medical request on October 11, 2007 was not answered. Plaintiff fails to allege facts to support that she had a serious medical need or how Rankin acted with deliberate indifference to that need. For these reasons, Plaintiff fails to state a claim against Nurse Rankin for deliberate indifference to her serious medical needs.

D. Hearing Officer King

In Count III, Plaintiff alleges that Hearing Officer King "continued to hear and give disciplinary proceedings that lead to closed custody classification" and that she has been placed in "disciplinary segregation" for almost 90 days. (Doc.# 3 at 5.) Pretrial detainees have a substantive due process right against restrictions that amount to punishment for criminal offenses.Valdez v. Rosenbaum, 302 F.3d 1039, 1045 (9th Cir. 2002) (citingUnited States v. Salerno, 481 U.S. 739, 746 (1987); Bell v. Wolfish, 441 U.S. 520, 535 (1979); Redman v. County of San Diego, 942 F.2d 1435, 1440-41 (9th Cir. 1991) ( en banc)). This right is violated if restrictions are "imposed for the purpose of punishment." Bell, 441 U.S. at 535. There is no constitutional infringement, however, if restrictions are "but an incident of some other legitimate government purpose." Id. In such a circumstance, governmental restrictions are permissible. Salerno, 481 U.S. at 747.

Plaintiff fails to allege facts to support that her confinement in disciplinary segregation is without some legitimate government purpose other than as punishment for the offenses with which she has been charged. She merely alleges that King was a hearing officer for disciplinary infractions. Such does not state a claim for violation of Plaintiff's due process rights.

V. Leave to Amend

For the foregoing reasons, Plaintiff's First Amended Complaint will be dismissed for failure to state a claim upon which relief may be granted. Within 30 days, Plaintiff may submit a second amended complaint to cure the deficiencies outlined above. The Clerk of Court will mail Plaintiff a court-approved form to use for filing a second amended complaint. If Plaintiff fails to use the court-approved form, the Court may strike the second amended complaint and dismiss this action without further notice to Plaintiff.

Plaintiff must clearly designate on the face of the document that it is the "Second Amended Complaint." The second amended complaint must be retyped or rewritten in its entirety on the court-approved form and may not incorporate any part of the original or First Amended Complaints by reference. Plaintiff may include only one claim per count.

A second amended complaint supersedes the original and first amended complaints. Ferdik v. Bonzelet, 963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner Co., 896 F.2d 1542, 1546 (9th Cir. 1990). After amendment, the Court will treat the prior complaints as nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised in a previous complaint is waived if it is not raised in a second amended complaint. King v. Atiyeh, 814 F.2d 565, 567 (9th Cir. 1987).

VI. Warnings

A. Release

Plaintiff must pay the unpaid balance of the filing fee within 120 days of her release. Also, within 30 days of her release, she must either (1) notify the Court that she intends to pay the balance or (2) show good cause, in writing, why she cannot. Failure to comply may result in dismissal of this action.

B. Address Changes

Plaintiff must file and serve a notice of a change of address in accordance with Rule 83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion for other relief with a notice of change of address. Failure to comply may result in dismissal of this action.

C. Copies

Plaintiff must submit an additional copy of every filing for use by the Court. See LRCiv 5.4. Failure to comply may result in the filing being stricken without further notice to Plaintiff.

D. Possible "Strike"

Because the First Amended Complaint has been dismissed for failure to state a claim, if Plaintiff fails to file a second amended complaint correcting the deficiencies identified in this Order, the dismissal will count as a "strike" under the "3-strikes" provision of 28 U.S.C. § 1915(g). Under the 3-strikes provision, a prisoner may not bring a civil action or appeal a civil judgment in forma pauperis under 28 U.S.C. § 1915 "if the prisoner has, on 3 or more prior occasions, while incarcerated or detained in any facility, brought an action or appeal in a court of the United States that was dismissed on the grounds that it is frivolous, malicious, or fails to state a claim upon which relief may be granted, unless the prisoner is under imminent danger of serious physical injury." 28 U.S.C. § 1915(g).

E. Possible Dismissal

If Plaintiff fails to timely comply with every provision of this Order, including these warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d at 1260-61 (a district court may dismiss an action for failure to comply with any order of the Court).

IT IS ORDERED:

(1) Plaintiff's Application to Proceed In Forma Pauperis is GRANTED. (Doc. # 8.)

(2) As required by the accompanying Order to the appropriate government agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing fee of $7.17.

(3) The First Amended Complaint (doc.# 3) is DISMISSED for failure to state a claim. Plaintiff has 30 days from the date this Order is filed to file a second amended complaint in compliance with this Order.

(4) If Plaintiff fails to file a second amended complaint within 30 days, the Clerk of Court must, without further notice, enter a judgment of dismissal of this action with prejudice that states that the dismissal counts as a "strike" under 28 U.S.C. § 1915(g).

(5) The Clerk of Court must mail Plaintiff a court-approved form for filing a civil rights complaint by a prisoner.

(6) The Clerk's Office must forward a copy of this Order to Plaintiff at the following address:

Camille Snowden, P307023

Estrella Jail

2939 W. Durango

Phoenix, AZ 85009

Instructions for a Prisoner Filing a Civil Rights Complaint in the United States District Court for the District of Arizona

1. Who May Use This Form. The civil rights complaint form is designed to help incarcerated persons prepare a complaint seeking relief for a violation of their federal civil rights. These complaints typically concern, but are not limited to, conditions of confinement. This form should not be used to challenge your conviction or sentence. If you want to challenge a state conviction or sentence, you should file a petition under 28 U.S.C. § 2254 for a writ of habeas corpus by a person in state custody. If you want to challenge a federal conviction or sentence, you should file a motion under 28 U.S.C. § 2255 to vacate sentence in the federal court that entered the judgment.

2. The Form. Local Rule of Civil Procedure (LRCiv) 3.4(a) provides that complaints by incarcerated persons must be filed on the court-approved form. The form must be typed or neatly handwritten. The form must be completely filled in to the extent applicable. All questions must be answered clearly and concisely in the appropriate space on the form. If needed, you may attach additional pages, but no more than fifteen additional pages, of standard letter-sized paper. You must identify which part of the complaint is being continued and number all pages. If you do not fill out the form properly, you will be asked to submit additional or corrected information, which may delay the processing of your action. You do not need to cite law.

3. Your Signature. You must tell the truth and sign the form. If you make a false statement of a material fact, you may be prosecuted for perjury.

4. The Filing Fee. The filing fee for this action is $350.00. If you are unable to immediately pay the filing fee, you may request leave to proceed in forma pauperis. Please review the "Information for Prisoners Seeking Leave to Proceed with a (Non-Habeas) Civil Action in Federal Court In Forma Pauperis Pursuant to 28 U.S.C. § 1915" for additional instructions.

5. Original and Judge's Copy. You must send an original plus one copy of your complaint and of any other documents submitted to the Court. You must send one additional copy to the Court if you wish to have a file-stamped copy of the document returned to you. All copies must be identical to the original. Copies may be legibly handwritten.

6. Where to File. You should file your complaint in the division where you were confined when your rights were allegedly violated. See LRCiv 5.1(a) and 77.1(a). If you were confined in Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. If you were confined in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott Division. If you were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file in the Tucson Division. Mail the original and one copy of the complaint with the $350 filing fee or the application to proceed in forma pauperis to: Phoenix Prescott Divisions: OR Tucson Division

: U.S. District Court Clerk U.S. District Court Clerk U.S. Courthouse, Suite 130 U.S. Courthouse, Suite 1500 401 West Washington Street, SPC 10 405 West Congress Street Phoenix, Arizona 85003-2119 Tucson, Arizona 85701-5010 7. Change of Address. You must immediately notify the Court and the defendants in writing of any change in your mailing address. Failure to notify the Court of any change in your mailing address may result in the dismissal of your case.

8. Certificate of Service. You must furnish the defendants with a copy of any document you submit to the Court (except the initial complaint and application to proceed in forma pauperis). Each original document (except the initial complaint and application to proceed in forma pauperis) must include a certificate of service on the last page of the document stating the date a copy of the document was mailed to the defendants and the address to which it was mailed. See Fed.R.Civ.P. 5(a), (d). Any document received by the Court that does not include a certificate of service may be stricken. A certificate of service should be in the following form:

I hereby certify that a copy of the foregoing document was mailed this ______________________ (month, day, year) to: Name: _______________________________ Address: ____________________________ Attorney for Defendant(s) _____________________________________ (Signature) 9. Amended Complaint. If you need to change any of the information in the initial complaint, you must file an amended complaint. The amended complaint must be written on the court-approved civil rights complaint form. You may file one amended complaint without leave (permission) of Court before any defendant has answered your original complaint. See Fed.R.Civ.P. 15(a). After any defendant has filed an answer, you must file a motion for leave to amend and lodge (submit) a proposed amended complaint. LRCiv 15.1. In addition, an amended complaint may not incorporate by reference any part of your prior complaint. LRCiv 15.1(a)(2). Any allegations or defendants not included in the amended complaint are considered dismissed. All amended complaints are subject to screening under the Prison Litigation Reform Act; screening your amendment will take additional processing time.

10. Exhibits. You should not submit exhibits with the complaint or amended complaint. Instead, the relevant information should be paraphrased. You should keep the exhibits to use to support or oppose a motion to dismiss, a motion for summary judgment, or at trial.

11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff of any judge. The only appropriate way to communicate with the Court is by filing a written pleading or motion.

12. Completing the Civil Rights Complaint Form.

HEADING:

Part A. JURISDICTION:

1. Your Name. Print your name, prison or inmate number, and institutional mailing address on the lines provided.

2. Defendants. If there are four or fewer defendants, print the name of each. If you name more than four defendants, print the name of the first defendant on the first line, write the words "and others" on the second line, and attach an additional page listing the names of all of the defendants. Insert the additional page after page 1 and number it "1-A" at the bottom.

3. Jury Demand. If you want a jury trial, you must write "JURY TRIAL DEMANDED" in the space below "CIVIL RIGHTS COMPLAINT BY A PRISONER." Failure to do so may result in the loss of the right to a jury trial. A jury trial is not available if you are seeking only injunctive relief.

1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. § 1983 for state, county, or city defendants; "Bivens v. Six Unknown Federal Narcotics Agents" for federal defendants; or "other." If you mark "other," identify the source of that authority.

2. Location. Identify the institution and city where the alleged violation of your rights occurred.

3. Defendants. Print all of the requested information about each of the defendants in the spaces provided. If you are naming more than four defendants, you must provide the necessary information about each additional defendant on separate pages labeled "2-A," "2-B," etc., at the bottom. Insert the additional page(s) immediately behind page 2.

Part C. CAUSE OF ACTION:

Part D. REQUEST FOR RELIEF:

one violation per count

1. Counts. You must identify which civil right was violated. You may allege the violation of only one civil right per count.

2. Issue Involved. Check the box that most closely identifies the issue involved in your claim. You may check only one box per count. If you check the box marked "Other," you must identify the specific issue involved.

3. Supporting Facts. After you have identified which civil right was violated, you must state the supporting facts. Be as specific as possible. You must state what each individual defendant did to violate your rights. If there is more than one defendant, you must identify which defendant did what act. You also should state the date(s) on which the act(s) occurred, if possible.

4. Injury. State precisely how you were injured by the alleged violation of your rights.

5. Administrative Remedies. You must exhaust any available administrative remedies before you file a civil rights complaint. See 42 U.S.C. § 1997e. Consequently, you should disclose whether you have exhausted the inmate grievance procedures or administrative appeals for each count in your complaint. If the grievance procedures were not available for any of your counts, fully explain why on the lines provided.

SIGNATURE:

You must sign your name and print the date you signed the complaint. Failure to sign the complaint will delay the processing of your action. Unless you are an attorney, you may not bring an action on behalf of anyone but yourself.

FINAL NOTE

You should follow these instructions carefully. Failure to do so may result in your complaint being stricken or dismissed. All questions must be answered concisely in the proper space on the form. If you need more space, you may attach no more than fifteen additional pages. But the form must be completely filled in to the extent applicable. If you attach additional pages, be sure to identify which section of the complaint is being continued and number the pages. (Failure to notify the Court of your change of address may result in dismissal of this action.) IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ARIZONA CASE NO. (1) (2) CIVIL RIGHTS COMPLAINT (3) BY A PRISONER (4) Check if there are additional Defendants and attach page 1-A listing them.

_______________________________________________________________ Name and Prisoner/Booking Number _______________________________________________________________ Place of Confinement _______________________________________________________________ Mailing Address _______________________________________________________________ City, State, Zip Code ) _________________________________________________________________________________, ) (Full Name of Plaintiff) Plaintiff, ) ) vs. ) ________________________________ ) (To be supplied by the Clerk) ______________________________________________________________________________, ) (Full Name of Defendant) ) ) ______________________________________________________________________________, ) ) ______________________________________________________________________________, ) ) ______________________________________________________________________________, ) Original Complaint Defendant(s). ) First Amended Complaint ___ ) Second Amended Complaint

A. JURISDICTION

28 U.S.C. § 1343 42 U.S.C. § 1983 28 U.S.C. § 1331Bivens v. Six Unknown Federal Narcotics Agents 403 U.S. 388 1. This Court has jurisdiction over this action pursuant to: (a); ; , (1971). Other: ____________________________________________________________________________________________________. 2. Institution/city where violation occurred: ___________________________________________________________________________.

B. DEFENDANTS

If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page. 1. Name of first Defendant: _____________________________________________________. The first Defendant is employed as: ________________________________________________________________ at ______________________________________________. (Position and Title) (Institution) 2. Name of second Defendant: __________________________________________________. The second Defendant is employed as: ________________________________________________________________ at ______________________________________________. (Position and Title) (Institution) 3. Name of third Defendant: ____________________________________________________. The third Defendant is employed as: ________________________________________________________________ at ______________________________________________. (Position and Title) (Institution) 4. Name of fourth Defendant: ____________________________________________________. The fourth Defendant is employed as: ________________________________________________________________ at ______________________________________________. (Position and Title) (Institution)

C. PREVIOUS LAWSUITS

If you filed more than three lawsuits, answer the questions listed above for each additional lawsuit on a separate page. 1. Have you filed any other lawsuits while you were a prisoner? Yes No 2. If yes, how many lawsuits have you filed? _____. Describe the previous lawsuits: a. First prior lawsuit: 1. Parties: ______________________________ v. ____________________________________________________________ 2. Court and case number: _______________________________________________________________________________. 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) _______________________________ ____________________________________________________________________________________________________________. b. Second prior lawsuit: 1. Parties: ______________________________ v. ____________________________________________________________ 2. Court and case number: _______________________________________________________________________________. 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) _______________________________ ____________________________________________________________________________________________________________. c. Third prior lawsuit: 1. Parties: ______________________________ v. ____________________________________________________________ 2. Court and case number: _______________________________________________________________________________. 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) _______________________________ ____________________________________________________________________________________________________________.

D. CAUSE OF ACTION COUNT I

Count I. only one. Supporting Facts. each Defendant Injury. Administrative Remedies. 1. State the constitutional or other federal civil right that was violated: ________________________________________ _________________________________________________________________________________________________________________. 2. Identify the issue involved. Check State additional issues in separate counts. Basic necessities Mail Access to the court Medical care Disciplinary proceedings Property Exercise of religion Retaliation Excessive force by an officer Threat to safety Other: ________________________________________________. 3. State as briefly as possible the FACTS supporting Count I. Describe exactly what did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments. ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________. 4. State how you were injured by the actions or inactions of the Defendant(s). ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________. 5. a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? Yes No b. Did you submit a request for administrative relief on Count I? Yes No c. Did you appeal your request for relief on Count I to the highest level? Yes No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. _________________________________________________________________________________________________ _____________________________________________________________________________________________________________.

COUNT II

Count II. only one. Supporting Facts. each Defendant Injury. Administrative Remedies: 1. State the constitutional or other federal civil right that was violated: _______________________________________ ________________________________________________________________________________________________________________. 2. Identify the issue involved. Check State additional issues in separate counts. Basic necessities Mail Access to the court Medical care Disciplinary proceedings Property Exercise of religion Retaliation Excessive force by an officer Threat to safety Other: _______________________________________________. 3. State as briefly as possible the FACTS supporting Count II. Describe exactly what did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments. ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________. 4. State how you were injured by the actions or inactions of the Defendant(s). ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________. 5. a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? Yes No b. Did you submit a request for administrative relief on Count II? Yes No c. Did you appeal your request for relief on Count II to the highest level? Yes No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. ________________________________________________________________________________________________ ____________________________________________________________________________________________________________.

COUNT III

Count III. only one. Supporting Facts. each Defendant Injury. Administrative Remedies. If you assert more than three Counts, answer the questions listed above for each additional Count on a separate page. 1. State the constitutional or other federal civil right that was violated: ________________________________________ ___________________________________________________________________________________________________________________. 2. Identify the issue involved. Check State additional issues in separate counts. Basic necessities Mail Access to the court Medical care Disciplinary proceedings Property Exercise of religion Retaliation Excessive force by an officer Threat to safety Other: ________________________________________________. 3. State as briefly as possible the FACTS supporting Count III. Describe exactly what did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments. ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________. 4. State how you were injured by the actions or inactions of the Defendant(s). ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________. 5. a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? Yes No b. Did you submit a request for administrative relief on Count III? Yes No c. Did you appeal your request for relief on Count III to the highest level? Yes No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. _________________________________________________________________________________________________ _____________________________________________________________________________________________________________.

E. REQUEST FOR RELIEF

State the relief you are seeking:

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

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

Executed on ______________________________________ _____________________________________________ DATE SIGNATURE OF PLAINTIFF __________________________________________________ (Name and title of paralegal, legal assistant, or other person who helped prepare this complaint) __________________________________________________ (Signature of attorney, if any) __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ (Attorney's address telephone number)

ADDITIONAL PAGES

All questions must be answered concisely in the proper space on the form. If you need more space, you may attach no more than fifteen additional pages. But the form must be completely filled in to the extent applicable. If you attach additional pages, be sure to identify which section of the complaint is being continued and number all pages.