Free Complaint Form (Prisoner) - Ohio

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO

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(ENTER ABOVE THE NAME OF THE PLAINTIFF IN THIS ACTION) IF THE PLAINTIFF IS A PRISONER: vs. PRISONER # ___________________

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(ENTER ABOVE THE NAME OF THE DEFENDANT IN THIS ACTION) IF THERE ARE ADDITIONAL DEFENDANTS PLEASE LIST THEM:

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COMPLAINT I. PARTIES TO THE ACTION: PLAINTIFF: PLACE YOUR NAME AND ADDRESS ON THE LINES BELOW. THE ADDRESS YOU GIVE MUST BE THE ADDRESS THAT THE COURT MAY CONTACT YOU AND MAIL DOCUMENTS TO YOU. A TELEPHONE NUMBER IS REQUIRED. ____________________________________________________________________ NAME - FULL NAME PLEASE - PRINT ____________________________________________________________________ ADDRESS: STREET, CITY, STATE AND ZIP CODE ____________________________________________________________________

____________________________________________________________________ TELEPHONE NUMBER IF THERE ARE ADDITIONAL PLAINTIFFS IN THIS SUIT, A SEPARATE PIECE OF PAPER SHOULD BE ATTACHED IMMEDIATELY BEHIND THIS PAGE WITH THEIR FULL NAMES, ADDRESSES AND TELEPHONE NUMBERS. IF NO ADDITIONAL PLAINTIFFS EXIST CONTINUE WITH THIS FORM. PAGE 2 AND 3 OF THIS FORM DEAL ONLY WITH A PLAINTIFF THAT IS INCARCERATED AT THE TIME OF FILING THIS COMPLAINT.

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IF YOU ARE A PRISONER FILING A CIVIL SUIT THE FOLLOWING INFORMATION IS REQUIRED: PREVIOUS LAWSUITS: A. HAVE YOU BEGUN OTHER LAWSUITS IN STATE OR FEDERAL COURT DEALING WITH THE SAME FACTS INVOLVED IN THIS ACTION OR OTHERWISE RELATING TO YOUR IMPRISONMENT? YES ( ) NO ( ) IF YOUR ANSWER TO A IS YES, DESCRIBE THE 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: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

B.

2.

COURT (IF FEDERAL COURT, NAME THE DISTRICT: IF STATE COURT , NAME THE COUNTY) ____________________________________________________________________

3.

DOCKET NUMBER ____________________________________________________________________

4.

NAME OF THE JUDGE TO WHOM THE CASE WAS ASSIGNED ____________________________________________________________________

5.

DISPOSITION (FOR EXAMPLE, WAS THE CASE DISMISSED? WAS IT APPEALED? IS IT STILL PENDING?) ____________________________________________________________________

6.

APPROXIMATE DATE OF THE FILING OF THE LAWSUIT ____________________________________________________________________

7.

APPROXIMATE DATE OF THE DISPOSITION ____________________________________________________________________

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PLACE OF PRESENT CONFINEMENT ____________________________________________________________________________________ A. IS THERE A PRISONER GRIEVANCE PROCEDURE IN THIS INSTITUTION? YES ( ) NO ( ) DID YOU PRESENT THE FACTS RELATING TO YOUR COMPLAINT IN THIS STATE PRISONER GRIEVANCE PROCEDURE? YES ( ) NO ( ) IF YOUR ANSWER IS YES: 1. WHAT STEPS DID YOU TAKE? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 2. WHAT WAS THE RESULT? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ D. IF YOUR ANSWER IS NO, EXPLAIN WHY NOT. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

B.

C.

E.

IF THERE IS NO PRISON GRIEVANCE PROCEDURE IN THIS INSTITUTION, DID YOU COMPLAIN TO PRISON AUTHORITIES? YES ( ) NO ( ) IF YOUR ANSWER IS YES: 1. WHAT STEPS DID YOU TAKE? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 2. WHAT WAS THE RESULT? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

F.

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DEFENDANTS: PLACE THE NAME AND ADDRESS OF EACH DEFENDANT YOU LISTED IN THE CAPTION ON THE FIRST PAGE OF THIS COMPLAINT. THIS FORM IS INVALID UNLESS EACH DEFENDANT APPEARS WITH FULL ADDRESS FOR PROPER SERVICE. 1. _______________________________________________________________________________ NAMES - FULL NAME PLEASE _______________________________________________________________________________ ADDRESS - STREET, CITY, STATE AND ZIP CODE 2. _______________________________________________________________________________ _______________________________________________________________________________ 3. _______________________________________________________________________________ _______________________________________________________________________________ 4. _______________________________________________________________________________ _______________________________________________________________________________ 5. _______________________________________________________________________________ _______________________________________________________________________________ 6. _______________________________________________________________________________ _______________________________________________________________________________

IF THERE ARE ADDITIONAL DEFENDANTS, PLEASE CONTINUE LISTING THEM.

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STATEMENT OF CLAIM PLEASE WRITE AS BRIEFLY AS POSSIBLE THE FACTS OF YOUR CASE. DESCRIBE HOW EACH DEFENDANT IS INVOLVED. INCLUDE THE NAME OF ALL PERSONS INVOLVED. GIVE DATES AND PLACES. DO NOT GIVE ANY LEGAL ARGUMENTS OR CITE ANY CASES OR STATUTES. IF YOU HAVE A NUMBER OF DIFFERENT CLAIMS; PLEASE NUMBER AND SET FORTH EACH CLAIM IN A SEPARATE PARAGRAPH. USE AS MUCH SPACE AS YOU NEED. YOU ARE NOT LIMITED TO THE PAPERS WE GIVE YOU. ATTACH EXTRA SHEETS THAT DEAL WITH YOUR STATEMENT CLAIM IMMEDIATELY BEHIND THIS PIECE OF PAPER. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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RELIEF IN THIS SECTION PLEASE STATE (WRITE) BRIEFLY EXACTLY WHAT YOU WANT THE COURT TO DO FOR YOU. MAKE NO LEGAL ARGUMENT, CITE NO CASES OR STATUTES. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

SIGNED THIS ________ DAY OF ____________________ 20____.

________________________________ SIGNATURE OF PLAINTIFF

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