Free Civil Rights Complaint Form for Prisoner - Alaska

Name Prison Number Place of confinement Mailing address City, State, Zip Telephone

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ALASKA

,
(Enter full name of plaintiff in this action)

Case No. Plaintiff,
vs.
(To be supplied by Court)

, , ,
(Enter full names of defendant(s) in this action. Do NOT use et al.)

PRISONER'S COMPLAINT UNDER THE CIVIL RIGHTS ACT 42 U.S.C. § 1983

Defendant(s). A. Jurisdiction Jurisdiction is invoked under 28 U.S.C. § 1343(a)(3). B. Parties 1. Plaintiff: This complaint alleges that the civil rights of
(print your name)

, , were

who presently resides at
(mailing address or place of confinement)

violated by the actions of the below named individual(s).

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2. Defendants (Make a copy of this page and provide same information if you are naming more than 3 defendants): Defendant No. 1,
(name)

, is a citizen of , and is employed as a .
(defendant's government position/title)

(state)

This defendant personally participated in causing my injury, and I want money damages. OR The policy or custom of this official's government agency violates my rights, and I seek injunctive relief (to stop or require someone do something). Defendant No. 2,
(name)

, is a citizen of , and is employed as .
(defendant's government position/title)

(state)

This defendant personally participated in causing my injury, and I want money damages. OR The policy or custom of this official's government agency violates my rights, and I seek injunctive relief (to stop or require someone do something). Defendant No. 3,
(name)

, is a citizen of , and is employed as a .
(defendant's government position/title)

(state)

This defendant personally participated in causing my injury, and I want money damages. OR The policy or custom of this official's government agency violates my rights, and I seek injunctive relief (to stop or require someone do something). C. Causes of Action (You may attach additional pages alleging other causes of action and facts supporting them
if necessary. Make copies of page 5 and rename them pages 5A, 5B, etc. and rename the claims, " Claim 4," "Claim 5, etc.").

Claim 1: On or about
(Date)

, my civil right to
(Right to medical care, access to courts, due process,

freedom of religion, free speech, freedom of association, freedom from cruel and unusual punishment, etc. List only one violation.)

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Supporting Facts: (Briefly describe facts you consider important to Claim 1. State what happened clearly, in your own words. DO NOT cite legal authority or argument. Be certain to describe exactly what each defendant, by name, did to violate the right alleged in Claim 1.)

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Claim 2: On or about
(Date)

, my civil right to
(Right to medical care, access to courts, due process,

freedom of religion, free speech, freedom of association, freedom from cruel and unusual punishment, etc. List only one violation.)

Supporting Facts: (Briefly describe facts you consider important to Claim 2. State what happened clearly, in your own words. DO NOT cite legal authority or argument. Be certain to describe exactly what each defendant, by name, did to violate the right alleged in Claim 2.)

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Claim 3: On or about
(Date)

, my civil right to
(Right to medical care, access to courts, due process,

freedom of religion, free speech, freedom of association, freedom from cruel and unusual punishment, etc. List only one violation.)

Supporting Facts: (Briefly describe facts you consider important to Claim 3. State what happened clearly, in your own words. DO NOT cite legal authority or argument. Be certain to describe exactly what each defendant, by name, did to violate the right alleged in Claim 3.)

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D. 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 your imprisonment? Yes No 2. If your answer is "Yes," describe each lawsuit. a. Lawsuit 1: Plaintiff(s): Defendant(s): Name and location of court:

Docket number: Approximate date case was filed: Disposition: Issues Raised: Dismissed

Name of judge: Date of final decision: Appealed Still pending

b. Lawsuit 2: Plaintiff(s): Defendant(s): Name and location of court:

Docket number: Approximate date case was filed: Disposition: Dismissed

Name of judge: Date of final decision: Appealed 6 of 10 Still pending
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Issues Raised:

3. Have you filed an action in federal court that was dismissed because it was determined to be frivolous, malicious, or failed to state a claim upon which relief could be granted? Yes No If your answer is "Yes," describe each lawsuit.

Lawsuit #1 dismissed as frivolous, malicious, or failed to state a claim: a. Defendant(s): b. Name of federal court c. The case was dismissed as: d. Issue(s) raised: frivolous, Case number: malicious and/or failed to state a claim

e. Approximate date case was filed:

Date of final decision:

Lawsuit #2 dismissed as frivolous, malicious, or failed to state a claim: a. Defendant(s): b. Name of federal court c. The case was dismissed as: d. Issue(s) raised: frivolous, Case number: malicious and/or failed to state a claim

e. Approximate date case was filed:

Date of final decision:

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Lawsuit #3 dismissed as frivolous, malicious, or failed to state a claim: a. Defendant(s): b. Name of federal court c. The case was dismissed as: d. Issue(s) raised: frivolous, Case number: malicious and/or failed to state a claim

e. Approximate date case was filed:

Date of final decision: Yes No

4. Are you in imminent danger of serious physical injury?

If your answer is "Yes," please describe how you are in danger, without legal argument/authority:

E. Exhaustion of Administrative Remedies ***REMINDER*** You must exhaust your administrative remedies before your claim can go forward. THE COURT MAY DISMISS ANY UNEXHAUSTED CLAIMS. 1. Present place of confinement: 2. Is there a grievance procedure at this institution? Yes No

3. If yes, did you present the facts in your complaint for review through the grievance procedure? Yes a. If your answer is "No," explain why not: No

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b. If your answer is "Yes," what steps did you take?

c. Is the grievance procedure complete?

Yes

No

If your answer is "Yes," ATTACH A COPY OF THE FINAL GRIEVANCE RESOLUTION for any grievance concerning facts relating to this case. F. Request for Relief Plaintiff requests that this Court grant the following relief: 1. Damages in the amount of $ 2. Punitive damages in the amount of $ 3. An order requiring defendant(s) to

4. A declaration that

5. Other:

Plaintiff demands a trial by jury.

Yes 9 of 10

No
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DECLARATION UNDER PENALTY OF PERJURY The undersigned declares under penalty of perjury that s/he is the plaintiff in the above action, that s/he has read the above civil rights complaint and that the information contained in the complaint is true and correct.
Executed at (Location) on (Date)

(Plaintiff's Signature)

Original Signature of Attorney (if any)

(Date)

Attorney's Address and Telephone Number

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