Free CIVIL RIGHTS COMPLAINT FORM - TO BE USED BY PRO SE (NON-PRISONER) LITIGANTS IN ACTIONS UNDER 28 U.S.C. § 1331 or § 1346 OR 42 U. - Florida

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION

CIVIL RIGHTS COMPLAINT FORM
TO BE USED BY PRO SE (NON-PRISONER) LITIGANTS IN ACTIONS UNDER 28 U.S.C. § 1331 or § 1346 OR 42 U.S.C. § 1983

, . (Enter full name of Plaintiff(s))

vs.

CASE NO: (To be assigned by Clerk) , , , , .

(Enter name and title of each Defendant. If additional space is required, use the blank area below and directly to the right.)

ANSWER ALL QUESTIONS ON THE FOLLOWING PAGES:

I. PLAINTIFF: State your full name and full mailing address in the lines below. Name of Plaintiff: Mailing address:

II. DEFENDANT(S): State the name of the Defendant in the first line, official position in the second line, place of employment in the third line, and mailing address. Do the same for every Defendant: (1) Defendant's name: Official position: Employed at: Mailing address:

(2)

Defendant's name: Official position: Employed at: Mailing address:

(3)

Defendant's name: Official position: Employed at: Mailing address:

(4)

Defendant's name: Official position: Employed at: Mailing address:

ATTACH ADDITIONAL PAGES HERE TO NAME ADDITIONAL DEFENDANTS

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III.

STATEMENT OF FACTS:
State briefly the FACTS of this case. Describe how each Defendant was involved and what each

person did or did not do which gives rise to your claim. In describing what happened, state the names of persons involved, dates, and place s. Do not m ake an y legal arg um ents or cite to any cases or statutes. You must set forth separate factua l allegation s in separately numbered paragraphs. You m ay m ak e copies of this page if necess ary to su pply all the fa cts. Barring extraordinary circums tances, no m ore than five (5) additional pages sho uld be attached . (If there are facts which are not related to this same basic incident or issue, they m ust be a ddres sed in a se parate civil rights co mp laint.)

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IV.

STATEMENT OF CLAIMS:
State what rights under the C onstitution, laws, or treaties of the Un ited States you claim have

bee n violate d. Be spe cific. Num ber e ach sep arate claim and relate it to the fac ts alleged in S ection III. If claims are n ot related to the sam e basic incid ent or issu e, they m ust be a ddres sed in a se parate civil rights com plaint.

V.

RELIEF REQUESTED:

State briefly what relief you seek from the Court. Do not mak e legal arguments or cite to cases/ statutes.

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS OF FACT, INCLUDING ALL CONTINUATION PAGES, ARE TRUE AND CORRECT.

(Date)

(Signature of Plaintiff)

Revised 07/02

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