Civil Complaint (To Be Used By Prisoner)

FORM TO BE USED BY A PRISONER IN FILING A CIVIL RIGHTS COMPLAINT IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA (1)_________________________________________ : (Name of Plaintiff) (Inmate Number) : : _________________________________________ : (Address) : : (2)_________________________________________ : (Name of Plaintiff) (Inmate Number) : : _________________________________________ : (Address) : : (Each named party must be numbered, and all names must be printed or typed) : : _____________________ (Case Number) : vs. : : (1)_________________________________________ : : (2)_________________________________________ : : (3)_________________________________________ : (Names of Defendants) : : (Each named party must be numbered, and all names must be printed or typed) : : CIVIL COMPLAINT TO BE FILED UNDER: 42 U.S.C. § 1983 - STATE OFFICIALS 28 U.S.C. § 1331 - FEDERAL OFFICIALS I. PREVIOUS LAWSUITS A. If you have filed any other lawsuits in federal court while a prisoner, please list the caption and case number including year, as well as the name of the judicial officer to whom it was assigned: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 1 American LegalNet, Inc. www.USCourtForms.com II. EXHAUSTION OF ADMINISTRATIVE REMEDIES In order to proceed in federal court, you must fully exhaust any available administrative remedies as to each ground on which you request action. A. B. Is there a prisoner grievance procedure available at your present institution? ____Yes ____No Have you fully exhausted your available administrative remedies regarding each of your present claims? ____Yes ____No If your answer to "B" is Yes: 1. What steps did you take? C. 2. What was the result? D. If your answer to "B" is No, explain why not: III. DEFENDANTS (1) Name of first defendant: Employed as at Mailing address: (2) Name of second defendant: Employed as at Mailing address: (3) Name of third defendant: Employed as at Mailing address: (List any additional defendants, their employment, and addresses on extra sheets if necessary) IV. STATEMENT OF CLAIM (State here as briefly as possible the facts of your case. Describe how each defendant is involved, including dates and places. Do not give any legal arguments or cite any cases or statutes. Attach no more than three extra sheets if necessary.) 1. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2 American LegalNet, Inc. www.USCourtForms.com ______________________________________________________________________________ 2. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ V. RELIEF (State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or statutes.) 1. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3 American LegalNet, Inc. www.USCourtForms.com ______________________________________________________________________________ I declare under penalty of perjury that the foregoing is true and correct. Signed this ____________ day of ______________________________, 19____. ______________________________________________________ (Signature of Plaintiff) 4 American LegalNet, Inc. www.USCourtForms.com