Free Civil Rights Complaint by a Prisoner - Hawaii

1983 FORM Rev. 01/2008

_________________________________________________________

Name and Prisoner/Booking Number
_________________________________________________________

Place of Confinement
_________________________________________________________

Mailing Address
_________________________________________________________

City, State, Zip Code

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF HAWAII
___________________________________________________________

Case No.
(To be supplied by the Clerk)

(Full Name of Plaintiff )

vs. ___________________________________

PRISONER CIVIL RIGHTS COMPLAINT

G Original Complaint G First Amended Complaint G Second Amended Complaint ___________________________________
(Full Names of Defendants; DO NOT USE et al. )

A. JURISDICTION 1. Jurisdiction is invoked pursuant to: a. G 28 U.S.C. § 1343(a)(3) ; 42 U.S.C. § 1983 b. G 28 U.S.C. § 1331; Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971) c. G Other: (Please Specify) ______________________________________________________ 2. Plaintiff: _________________________________________________________________________ Institution/city where violation occurred: ________________________________________________ 3. First Defendant *: This defendant is a citizen of (state and county) ____________________ _______________________, and is employed as: at
(Position and Title) (Institution)

.

This defendant is sued in his/her ___ individual ___ official capacity (check one or both). Explain how 1

1983 FORM Rev. 01/2008

this defendant was acting under color of law: ____________________________________________________________________________________ ____________________________________________________________________________________ 4. Second Defendant: This defendant is a citizen of (state and county) ____________________ ________________________, and is employed as: at
(Position and Title) (Institution)

This defendant is sued in his/her ___ individual ___ official capacity (check one or both). Explain how this defendant was acting under color of law: ____________________________________________________________________________________ ____________________________________________________________________________________ 5. Third Defendant: This defendant is a citizen of (state and county) ____________________ ________________________, and is employed as: at
(Position and Title) (Institution)

This defendant is sued in his/her ___ individual ___ official capacity (check one or both). Explain how this defendant was acting under color of law: ____________________________________________________________________________________ ____________________________________________________________________________________
(If you would like to name additional defendants, make a copy of this (blank) page and provide the necessary information.)

* A defendant may be named in an individual or official capacity, or both. To sue a defendant in their individual capacity, you must be able to state facts showing that the defendant was actually involved in violating your rights. A suit against a defendant in their official capacity is in reality a suit against the office or position the defendant holds. Only injunctive relief is available in an official capacity suit against a state official. This is because the Eleventh Amendment confers immunity upon the state or its officials against monetary damages resulting from federal court litigation.
"Color of law" refers to whether the person is a private party or an employee, official, or agent of a state, county, city, or the federal government. There can be no civil rights action under § 1983 unless the defendant was "acting under color of law." After the color of law requirement is met, then it must be determined in which capacity the defendant is being sued.

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1983 FORM Rev. 01/2008

B. PREVIOUS LAWSUITS 1. Have you brought any other lawsuits while a prisoner: 2. If your answer is yes, how many?: 3. First previous lawsuit: a. Plaintiff Defendants b. Court and Case Number (if federal court, identify the district; if state court, identify the county):

9 Yes

9 No

Describe the lawsuit in the spaces below.

c. d.

Claims raised: Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?)

e. f.

Approximate date of filing lawsuit Approximate date of disposition

4. Second previous lawsuit: a. Plaintiff Defendants b. Court and Case Number (if federal court, identify the district; if state court, identify the county):

c. d.

Claims raised: Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?)

e. f.

Approximate date of filing lawsuit Approximate date of disposition

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1983 FORM Rev. 01/2008

5. Third previous lawsuit: a. Plaintiff Defendants b. Court and Case Number (if federal court, identify the district; if state sourt, identify the county):

c. d.

Claims raised: Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?)

e. f.

Approximate date of filing lawsuit Approximate date of disposition

(If you have filed more than three lawsuits, make a copy of this (blank) page and provide the necessary information.)

6.

Have you filed any actions in federal court that were dismissed because they were frivolous, malicious, or failed to state a claim upon which relief could be granted? ___Yes ___No.
If you have had three or more previous federal actions dismissed for any of the reasons stated above, you may not bring another civil action in forma pauperis unless you are under imminent danger of serious physical injury. See 28 U.S.C. § 1915(g).

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1983 FORM Rev. 01/2008

C. CAUSE OF ACTION COUNT I 1. The following constitutional or other federal civil right has been violated by the Defendant(s): ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Count I involves: (Check only one; if your claim involves more than one issue, each issue should be stated in a different count)

G Disciplinary proceedings G Excessive force by an officer

GMail G Access to the court GMedical care GProperty G Exercise of religion GRetaliation GThreat to safety GOther:___________________________

3. Supporting Facts: (State as briefly as possible the FACTS supporting Count I, without citing legal authority or arguments. Describe exactly what each Defendant did or did not do to violate your rights.)

4. Injury: (State how you have been injured by Defendant(s)' actions or inactions. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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1983 FORM Rev. 01/2008

COUNT II 1. The following constitutional or other federal civil right has been violated by the Defendant(s): ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Count II involves: (Check only one; if your claim involves more than one issue, each issue should be stated in a different count)

G Disciplinary proceedings G Excessive force by an officer

GMail G Access to the court GMedical care GProperty G Exercise of religion GRetaliation GThreat to safety GOther:___________________________

3. Supporting Facts:(State as briefly as possible the FACTS supporting Count II, without citing legal authority or arguments. Describe exactly what each Defendant did or did not do to violate your rights.)

4. Injury: (State how you have been injured by Defendant(s)' actions or inactions. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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1983 FORM Rev. 01/2008

COUNT III 1. The following constitutional or other federal civil right has been violated by the Defendant(s): ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Count III involves: (Check only one; if your claim involves more than one issue, each issue should be stated in a different count)

G Disciplinary proceedings G Excessive force by an officer

GMail G Access to the court GMedical care GProperty G Exercise of religion GRetaliation GThreat to safety GOther:___________________________

3. Supporting Facts: (State as briefly as possible the FACTS supporting Count III, without citing legal authority or arguments. Describe exactly what each Defendant did or did not do to violate your rights.)

4. Injury: (State how you have been injured by Defendant(s)' actions or inactions. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
(If you assert more than three Counts, make a copy of this (blank) page and provide the necessary information.)

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1983 FORM Rev. 01/2008

D. REQUEST FOR RELIEF
State briefly exactly what you want the Court to do for you. Make no legal arguments. Cite no cases or statutes.

____________________________________________________________________________________

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

I understand that a false statement or answer to any question in this complaint will subject me to penalties of perjury. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT THE FOREGOING IS TRUE AND CORRECT. See 28 U.S.C. § 1746 and 18 U.S.C. §1621. Signed this day of
(month)

,
(year)

.

(Signature of Plaintiff)

ADDITIONAL PAGES All questions must be answered concisely in the proper space on the form. If needed, you may attach no more than fifteen (15) additional pages. Number these pages in relation to the final page number of the section that is being extended (i.e. additional defendants' pages should be numbered "2A, 2B, etc.," additional previous lawsuits' pages "4A, 4B, etc.," additional claims should be numbered "7A, 7B, etc." This form, however, must be completely filled in to the extent applicable.

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