Free District of Montana Civil Complaint Form - Montana

Check the box next to the best description of your cause of action. Choose only one: Prisoner Civil Rights Non-Prisoner Civil Rights Personal Injury/Tort Tax Collection Practices Employment Discrimination Other (specify) _____________________ 9 9 9 9 9 9

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MONTANA __________________________________ DIVISION
(You must fill in this blank. See Instruction 6.) _________________________________________ _________________________________________, (Full name of Plaintiff and prisoner number, if any)

Cause No._______________________
(to be filled in by Clerk of Court)

Plaintiffs, COMPLAINT vs.
_________________________________________ _________________________________________ _________________________________________, (Full name of each defendant. Do not use et. al.)

Jury Trial Demanded Jury Trial Not Demanded

9 9

Defendants.
INSTRUCTIONS 1. Use this form to file a civil complaint with the United States District Court for the District of Montana. You may attach additional pages where necessary. 2. Your complaint must include only counts/causes of action and facts ­ not legal arguments or citations. Complaint (Revised 5/09) Page 1 of 7

Plaintiff's Last Name ___________________________________

3. Your complaint must be typed or legibly handwritten. All pleadings and other papers submitted for filing must be on 8 ½" x 11" paper (letter size). Each plaintiff must sign the complaint (see page 7). The signatures need not be notarized. However, each signature must be an original and not a copy. You must pay the Clerk for copies of your complaint or other court records, even if you are proceeding in forma pauperis. The cost for copies is $0.50 per page and prepayment is required. 4. The filing fee for a complaint is $350.00. The filing fee is set by Congress and cannot be changed by the Court. In addition, you will be required to pay the cost of serving the complaint on each of the defendants. If you are unable to prepay the entire filing fee and service costs for this action, you may move to proceed in forma pauperis. Your complaint will be returned to you without filing if it is not accompanied by either the full filing fee or a motion to proceed in forma pauperis. Please note that prisoners proceeding in forma pauperis are required to pay the full filing fee in installments. 5. Complaints submitted by persons proceeding in forma pauperis and complaints submitted by prisoners suing a governmental entity or employee are reviewed by the Court before the defendants are required to answer. See 28 U.S.C. §§ 1915(e)(2), 1915A(a); 42 U.S.C. § 1997e(c). After the Court completes the review process, you will receive an Order explaining the findings and any further action you may or must take. The review process may take a few months; each case receives the judge's individual attention. 6. Pursuant to Standing Order DWM 27, "no prisoner may maintain more than two (2) civil actions in forma pauperis at one time, unless the prisoner shows that he or she is under imminent danger of serious physical injury." 7. The case caption (page 1 of this form) must indicate the proper Division for filing. A Division where the alleged wrong(s) occurred is a proper Division. When you have completed your complaint, mail the original of your complaint and either the full filing fee or your motion to proceed in forma pauperis to the proper Division: Billings Division: Clerk of U.S. District Court, 316 N. 26th, Room 5405, Billings, MT 59101 (Big Horn, Carbon, Carter, Custer, Dawson, Fallon, Garfield, Golden Valley, McCone, Musselshell, Park, Petroleum, Powder River, Prairie, Richland, Rosebud, Stillwater, Sweetgrass, Treasure, Wheatland, Wibaux or Yellowstone County) Butte Division: Clerk of U.S. District Court, 400 N. Main St., Federal Bldg. Rm. 303, Butte, MT 59701 (Beaverhead, Deer Lodge, Gallatin, Madison, or Silver Bow County)

Plaintiff's Last Name ___________________________________

Complaint (Revised 5/09) Page 2 of 7

Great Falls Division: Clerk of U.S. District Court, 215 1st Ave. North, P.O. Box 2186, Great Falls, MT 59403 (Blaine, Cascade, Chouteau, Daniels, Fergus, Glacier, Hill, Judith Basin, Liberty, Phillips, Pondera, Roosevelt, Sheridan, Teton, Toole, or Valley County) Crossroads Correctional Center is located in Toole County Helena Division: Clerk of U.S. District Court, 901 Front St., Ste 2100, Helena, MT 59626 (Broadwater, Jefferson, Lewis & Clark, Meagher, or Powell County) Montana State Prison is located in Powell County Clerk of the U.S. District Court, 201 E. Broadway, P.O. Box 8537, Missoula, MT 59807 (Flathead, Granite, Lake, Lincoln, Mineral, Missoula, Ravalli, or Sanders County)

Missoula Division:

COMPLAINT
I. PLACE OF CONFINEMENT A. Are you incarcerated? Yes G No G (if No, go to Part II)

B. If yes, where are you currently incarcerated? __________________________________________________________________ C. If any of the incidents giving rise to your complaint occurred in a different facility, list that facility: __________________________________________________________________ II. EXHAUSTION OF ADMINISTRATIVE REMEDIES A. Non-Prisoners 1. Does any cause of action alleged in this complaint require you to exhaust administrative remedies before filing in court? Yes G No G Don't Know 9 2. If yes, have you exhausted your administrative remedies? Yes G No G

Plaintiff's Last Name ___________________________________

Complaint (Revised 5/09) Page 3 of 7

B. Prisoners (If you listed other institutions in I.C above, please answer for each institution). 1. Is there a grievance procedure in your current institution? Yes G No G

2. Did you fully exhaust the administrative grievance process within the jail or prison where the incidents at issue occurred? Yes G No G 3. If you did not fully exhaust the grievance process, explain why: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ III. PARTIES TO CURRENT LAWSUIT A. Plaintiff ____________________is a citizen of ________________________, (State) presently residing at________________________________________________. (Mailing address or place of confinement) B. Defendant ____________________is a citizen of ______________________, (State) employed as _____________________at_______________________________. (Position and Title, if any) (Institution/Organization) Defendant ____________________is a citizen of ______________________, (State) employed as _____________________at_______________________________. (Position and Title, if any) (Institution/Organization) Defendant ____________________is a citizen of ______________________, (State) employed as _____________________at_______________________________. (Position and Title, if any) (Institution/Organization)
(NOTE: If more space is needed to furnish the above information, continue on a blank sheet labeled "APPENDIX A: PARTIES").

Plaintiff's Last Name ___________________________________

Complaint (Revised 5/09) Page 4 of 7

IV. STATEMENT OF CLAIMS A. Count I (State your cause of action, e.g., how have your constitutional rights been violated): __________________________________________________________________ __________________________________________________________________ Date of incident(s): __________________________________________________ 1. Supporting Facts: (Include all facts you consider important, including names of persons involved, places, and dates. State the facts clearly in your own words without citing legal arguments, cases, or statutes). __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. Defendants Involved: (List the name of each defendant involved in this claim and specifically describe what each defendant did or did not do to allegedly cause your injury). __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
(NOTE: For each additional claim, use a blank sheet labeled "APPENDIX B. STATEMENT OF CLAIMS." You must set forth two paragraphs for each count, one consisting of Supporting Facts (following the directions under IV(A)(1)), and one consisting of Defendants Involved (following the directions under IV(A)(2)).

Plaintiff's Last Name ___________________________________

Complaint (Revised 5/09) Page 5 of 7

V. INJURY Describe the injuries you suffered as a result of each individual defendant's actions. (Do no cite legal arguments, cases, or statutes). __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
(NOTE: If more space is needed to furnish the above information, continue on a blank sheet labeled "APPENDIX C: INJURY").

VI. REQUEST FOR RELIEF Describe the relief you request. (Do no cite legal arguments, cases, or statutes). __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
(NOTE: If more space is needed to furnish the above information, continue on a blank sheet labeled "APPENDIX D: REQUEST FOR RELIEF").

Plaintiff's Last Name ___________________________________

Complaint (Revised 5/09) Page 6 of 7

VII. PLAINTIFF'S DECLARATION A. I understand I must keep the Court informed of my current mailing address and my failure to do so may result in dismissal of this Complaint without notice to me. B. I understand the Federal Rules of Civil Procedure prohibit litigants filing civil complaints from using certain information in documents submitted to the Court. In order to comply with these rules, I understand that: · social security numbers, taxpayer identification numbers, and financial account numbers must include only the last four digits (e.g. xxx-xx-5271, xx-xxx5271, xxxxxxxx3567); · birth dates must include the year of birth only (e.g. xx/xx/2001); and · names of persons under the age of 18 must include initials only (e.g. L.K.). If my documents (including exhibits) contain any of the above listed information, I understand it is my responsibility to black that information out before sending those documents to the Court. I understand I am responsible for protecting the privacy of this information. C. I declare under penalty of perjury that I am the plaintiff in this action, I have read this complaint, and the information I set forth herein is true and correct. 28 U.S.C. § 1746; 18 U.S.C. § 1621. D. (Prisoners Only) This Complaint was deposited in the prison system for legal mail, postage prepaid or paid by the prison, on ________________________________________, 20_____. Executed at ________________________on ____________________, 20_____. (Location) (Date) _____________________________________________ Signature of Plaintiff
(If there is more than one Plaintiff, each Plaintiff must sign the complaint using a separate declarations page). Complaint (Revised 5/09) Plaintiff's Last Name ___________________________________ Page 7 of 7