Pro Se Prisoner Civil Rights Complaint

(Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE (In the space above enter the full name(s) of the plaintiff(s).) Civ. Action No. _ ___ (To be assigned by Clerk's Office) -against- COMPLAINT (Pro Se Prisoner) Jury Demand? Yes No (In the space above enter the full name(s) of the defendant(s). If you cannot fit the names of all of the defendants in the space provided, please write "see attached" in the space above and attach an additional sheet of paper with the full list of names. The names listed in the above caption must be identical to those contained in Section IV. Do not include addresses here.) NOTICE Federal Rule of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to electronic court files. Under this rule, papers filed with the court should not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number. A filing may include only: the last four digits of a social security number; the year of an individual's birth; a minor's initials; and the last four digits of a financial account number. Plaintiff need not send exhibits, affidavits, grievance or witness statements, or any other materials to the Clerk's Office with this complaint. Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint I. COMPLAINT Indicate below the federal legal basis for your claim, if known. This form is designed primarily for pro se prisoners challenging the constitutionality of their conditions of confinement, claims which are often brought under 42 U.S.C. § 1983 (against state, county, or municipal defendants) or in a "Bivens" action (against federal defendants). Check one: II. 42 U.S.C. § 1983 (state, county, or municipal defendants) Action under Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971) (federal defendants) PLAINTIFF INFORMATION Name (Last, First, MI) Prisoner ID # Place of Detention Aliases Institutional Address County, City III. PRISONER STATUS State Zip Code Indicate whether you are a prisoner or other confined person as follows: Pretrial detainee Civilly committed detainee Immigration detainee Convicted and sentenced state prisoner Convicted and sentenced federal prisoner Page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint IV. DEFENDANT(S) INFORMATION Please list the following information for each defendant. If the correct information is not provided, it could result in the delay or prevention of service. Make sure that the defendant(s) listed below are identical to those contained in the above caption. Attach additional sheets of paper as necessary. Defendant 1: Name (Last, First) Current Job Title Current Work Address County, City State Zip Code Defendant 2: Name (Last, First) Current Job Title Current Work Address County, City State Zip Code Page 3 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint Defendant(s) Continued Defendant 3: Name (Last, First) Current Job Title Current Work Address County, City State Zip Code Defendant 4: Name (Last, First) Current Job Title Current Work Address County, City State Zip Code Page 4 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint V. STATEMENT OF CLAIM Place(s) of occurrence: Date(s) of occurrence: State which of your federal constitutional or federal statutory rights have been violated: State here briefly the FACTS that support your case. Describe how each defendant was personally involved in the alleged wrongful actions, state whether you were physically injured as a result of those actions, and if so, state your injury and what medical attention was provided to you. FACTS: What happened to you? Page 5 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint Who did what? Page 6 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint Was anyone else involved? Page 7 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint VI. ADMINISTRATIVE PROCEDURES WARNING: Prisoners must exhaust administrative procedures before filing an action in federal court about prison conditions. 42 U.S.C. § 1997e(a). Your case may be dismissed if you have not exhausted your administrative remedies. Is there a grievance procedure available at your institution? Yes No No Have you filed a grievance concerning the facts relating to this complaint? Yes If no, explain why not: Is the grievance process completed? If no, explain why not: Yes No VII. RELIEF State briefly what you want the court to do for you. Make no legal arguments. Cite no cases or statutes. Page 8 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint VIII. PRISONER'S LITIGATION HISTORY The "three strikes rule" bars a prisoner from bringing a civil action or an appeal in forma pauperis in federal court if that 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 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). Have you brought any other lawsuits in state or federal court while a prisoner? If yes, how many? Number each different lawsuit below and include the following: · · · Name of case (including defendants' names), court, and docket number Nature of claim made How did it end? (For example, if it was dismissed, appealed, or is still pending, explain below.) Yes No Page 9 of 10 American LegalNet, Inc. www.FormsWorkFlow.com (Del. Rev. 11/14) Pro Se Prisoner Civil Rights Complaint IX. PLAINTIFF'S DECLARATION AND WARNING Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my knowledge, information, and belief that this complaint: (1) is not being presented for an improper purpose, such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation; (2) is supported by existing law or by a nonfrivolous ar