Free Civil Rights Complaint Form for Non-Prisoner - Alaska

Name

Mailing address

Telephone

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ALASKA

,
(Full name of plaintiff in this action)

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

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

COMPLAINT UNDER THE CIVIL RIGHTS ACT 42 U.S.C. § 1983
(NON-PRISONERS)

Defendant(s). A. Jurisdiction Jurisdiction is invoked under 28 U.S.C. § 1343(a)(3) and 42 U.S.C. § 1983. If you assert jurisdiction under any different or additional authorities, list them below:

B. Parties 1. Plaintiff: This complaint alleges that the civil rights of
(print your name)

, , were

who presently resides at
(mailing address)

violated by the actions of the below named individual(s).
PS 02 (4/06)

Page 1 of 8

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.)

Page 2 of 8

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.)

Page 3 of 8

Claim 2: The following civil right has been violated:
(e.g., due process, freedom of religion, free speech, freedom of association and/or assembly, freedom from cruel and unusual punishment, etc. List only one civil right 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. Include dates.)

Page 4 of 8

Claim 3: The following civil right has been violated:
(e.g., due process, freedom of religion, free speech, freedom of association and/or assembly, freedom from cruel and unusual punishment, etc. List only one civil right 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. Include dates.)

Page 5 of 8

D. Previous Lawsuits 1. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action? Yes No

2. If your answer is "Yes," describe each lawsuit. (If there is more than one lawsuit, describe the additional lawsuits by copying this blank page and labeling it page "6A.") a. Parties to previous lawsuit: Plaintiff(s):

Defendant(s):

b. Name and location of court:

c. Docket number: d. Name of judge to whom case was assigned: e. Disposition:
(For example, was the case dismissed, appealed or still pending?)

f. Issues Raised:

g. Approximate date case was filed: h. Approximate date of final decision: Page 6 of 8

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

Court. (Choose one.)

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.
Plaintiff's Original Signature

Plaintiff's Full Name

Executed at (Location)

on (Date)

Page 7 of 8

Original Signature of Attorney (if any)

(Date)

Attorney's Address and Telephone Number

Page 8 of 8