Free Civil Rights Form Complaint - Connecticut

UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT CIVIL RIGHTS COMPLAINT
____________________________ ____________________________, Plaintiff(s), (Full name(s); Do not use et al.) v. _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ Defendant(s). (Full name(s) and capacity, e.g., official capacity, individual capacity, or official and individual capacitites) (Do not use et al.) Case No. __________________ (To be supplied by the court)

A. PARTIES 1. ________________________________ is a citizen of _________________________ who (Plaintiff) (State) presently resides at __________________________________________________________. (mailing address) 2. Defendant _________________________________ is a citizen of ___________________ (name of first defendant) (State) whose address is____________________________________________________________,

and who is employed as ________________________________________________. (title and place of employment)

At the time the claim(s) alleged in this complaint arose, was this defendant acting under color of state law? __ Yes __ No. If your answer is "Yes," briefly explain: ___________________________________________________________________________ ___________________________________________________________________________

3. Defendant ________________________________ is a citizen of ____________________ (name of second defendant) (State) whose address is ____________________________________________________________ and who is employed as ______________________________________________. (title and place of employment) At the time the claim(s) alleged in this complaint arose, was this defendant acting under color of state law? __ Yes __ No. If your answer is "Yes," briefly explain: ___________________________________________________________________________ ___________________________________________________________________________ (If more space is needed to furnish the above information for additional defendants, continue on a blank sheet which you should label "A. PARTIES." Be sure to include each defendant's complete address and title.)

B. JURISDICTION 1. Jurisdiction is asserted pursuant to (CHECK ONE) 42 U.S.C. § 1983 (applies to state defendants) Bivens v. Six Unknown Named Agents of Fed. Bureau of Narcotics, 403 U.S. 388 (1971) and 28 U.S.C. § 1331 (applies to federal defendants) 2. Jurisdiction also is invoked pursuant to 28 U.S.C. § 1343(a)(3). (If you wish to assert jurisdiction under different or additional statutes, you may list them below.) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

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C. NATURE OF THE CASE BRIEFLY state the background of your case.

D. CAUSE OF ACTION I allege that the following of my constitutional rights, privileges, or immunities have been violated and that the following facts form the basis of my allegations: (If more space is needed to explain any allegation or to list additional supporting facts, continue on a blank sheet which you should label "D. CAUSE OF ACTION.") Claim I: ________________________________________________________________

___________________________________________________________________________ ___________________________________________________________________________ Supporting Facts: (Include all facts you consider important, including names of persons involved, places, and dates. Describe exactly how each defendant is involved. State the facts clearly in your own words without citing legal authority or argument.)

Claim II: __________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

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Supporting Facts:

Claim III:

________________________________________________________________

___________________________________________________________________________ ___________________________________________________________________________ Supporting Facts:

E. PREVIOUS LAWSUITS 1. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action or otherwise relating to the conditions of your imprisonment? __Yes __No. If your answer is "Yes," describe each lawsuit. (If there is more than one lawsuit, describe the additional lawsuits using this same format on a blank sheet which you should label "E. PREVIOUS LAWSUITS.") a. Parties to previous lawsuit: Plaintiff(s): Defendant(s): b. Name and location of court and docket number 4

c. Disposition of lawsuit. (For example, was the case dismissed? Was it appealed? Is it still pending?)

d. Issues raised: ___________________________________________________________

e. Approximate date of filing lawsuit:____________________________ f. Approximate date of disposition: ______________________________ 2. If you have filed other lawsuits in this court in the last ten (10) years that are not related to the acts complained of in Part D, please list them. (If you need additional space, use a blank sheet which you should label "E. PREVIOUS LAWSUITS.") ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

F. REQUEST FOR RELIEF I request the following relief:

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G. JURY DEMAND Do you wish to have a jury trial? Yes _____________________________ Original signature of attorney (if any) ______________________________ Printed Name No __ ______________________________ Plaintiff's Original Signature

Printed Name

( ) Attorney's full address and telephone

( ) Plaintiff's full address and telephone

Email address if available

Email address if available

DECLARATION UNDER PENALTY OF PERJURY
The undersigned declares under penalty of perjury that he/she is the plaintiff in the above action, that he/she has read the above complaint and that the information contained in the complaint is true and correct. 28 U.S.C. § 1746; 18 U.S.C. § 1621. Executed at _________________________ on ________________________. (location) (date) Plaintiff's Original Signature
(Rev. 9/24/08)

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