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Complaint For Violation Of Civil Rights - District Of Columbia
| Complaint For Violation Of Civil Rights Form. This is a District Of Columbia form and can be used in USDC-District of Columbia Federal . |
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UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA ______________________________) ______________________________) ______________________________) ______________________________) (Enter your full name, prison number and address) v. CIVIL ACTION NO._____________ (To be supplied by the Clerk of the District Court) ______________________________) ______________________________) ______________________________) ______________________________) (Enter the full name and address(es), if known, of defendant(s) in this action) COMPLAINT FOR VIOLATION OF CIVIL RIGHTS Instructions for filing a Complaint by a Prisoner Under the Civil Rights Act, 42 U.S.C. '1983 This packet contains one copy of a complaint form and one copy of an application to proceed in forma pauperis. To start an action, you must file an original and one copy of this complaint form. Your complaint must be clearly handwritten or typewritten and you must sign and declare under penalty of perjury that the facts are correct. If you need additional space to answer a question, you may use another blank page. Your complaint can be brought in this Court only if one or more of the named defendants is located within the District of Columbia. Further, you must file a separate complaint for each claim that you have unless they are related to the same incident or problem. The law requires that you state only facts in your complaint. You must supply a certified copy of your prison trust account, pursuant to the provisions of 28 U.S.C. '1915, effective April 26, 1996. The filing fee is $250.00. If insufficient funds exist in your prison account at the time of filing your complaint, the court must assess, and when funds exist, collect an initial filing fee equal to 20 percent of the greater of: (1) (2) the average monthly deposits to your prison account, or the average monthly balance of your prison account for the prior six-month period. American LegalNet, Inc. www.USCourtForms.com Thereafter, you are required to make monthly payments of 20% of the preceding month=s income. The agency having custody over you must forward payments from your account to the clerk of the court each time the amount in the account exceeds $10.00 until the filing fees are paid. Therefore, before an assessment can be made regarding your ability to pay, you must submit a certified copy of your prison account for the prior six-month period. When this form is completed, mail it and the copies to the Clerk of United States District Court for the District of Columbia, 333 Constitution Ave., NW, Washington, D.C. 20001. I. SUCCESSIVE CLAIMS Pursuant to the Prison Litigation Reform Act of 1995, unless a prisoner claims to be in Aimminent danger of serious physical injury,@ he or she may not file a civil action or pursue a civil appeal in forma pauperis Aif the prisoner has, on three or more 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 they failed to state a claim upon which relief could be granted.@ II. PREVIOUS LAWSUITS A. Have you begun other lawsuits in state or federal court dealing with the same or similar facts involved in this action? Yes ( ) No ( ) Have you begun other lawsuits in state or federal court relating to your imprisonment? Yes () No ( ) If your answer to A or B is Yes, describe each 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. Plaintiffs:______________________________________________ ______________________________________________________ Defendants:____________________________________________ ______________________________________________________ 2. Court (if federal court, name the district; if state court, name the county) ______________________________________________________ Docket number__________________________________________ Name of judge to whom case was assigned:____________________ B. C. 3. 4. . American LegalNet, Inc. www.USCourtForms.com 5. Disposition (for example: Was the case dismissed? Was it appealed? Is it still pending?)__________________________________________ _____________________________________________________ Approximate date of filing lawsuit:_________________________ _____________________________________________________ Approximate date of disposition:___________________________ ______________________________________________________ 6. 7. III. PLACE OF CONFINEMENT ________________________________________________________________________ ________________________________________________________________________ A. Is there a prisoner grievance procedure in this institution? Yes ( ) No ( ) If your answer is Yes, go to Question III B. If your answer is No, skip Question III B,C and D and go to Question III E. Did you present the facts relating to your complaint in the prisoner grievance procedure? Yes ( ) No ( ) If your answer is Yes to Question III B; 1. To whom and when did you complain?_______________________ ______________________________________________________ Did you complain in writing? (Furnish copy of the complaint you made, if you have one.) Yes ( ) No ( ) What, if any, response did you receive? (Furnish copy of response, if in writing.) ______________________________________________ _______________________________________________________ What happened as a result of your complaint? ______________________ ____________________________________________________________ ____________________________________________________________ B. C. 2. 3. 4. D. If your answer is No to Question III B, explain why not. _____________________ __________________________________________________________________ __________________________________________________________________ If there is no prison grievance procedure in the institution, did you complain to prison authorities? Yes ( ) No ( ) If your answer is Yes to Question III E; American LegalNet, Inc. www.USCourtForms.com E. F. 1. 2. To whom and when did you complain? ___________________________ ____________________________________________________________ Did you complain in writing? (Furnish copy of the complaint you made, if you have one.) What, if any, response did you receive? (Furnish copy of response if in writing) _____________________________________________________ __________________________
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