Free PDF - Indiana

Full name(s)

Street address or postal box number

City, State and zip code ________________________________________ Phone Number

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF INDIANA
Civil Action No. (To be supplied by the Court)

Plaintiff(s) Full name(s) (Do not use et al.) v.

___________________________________________ ___________________________________________ ___________________________________________Defendant(s). (Enter above the full name of ALL defendants in this action. Do not use "et al".)

CIVIL RIGHTS COMPLAINT

I. PARTIES 1. Plaintiff's Information: Name and Prisoner Number of Plaintiff:______________________________________________ Present Place of Confinement or Mailing Address:______________________________________ ____________________________________________________________________________________ 2. Defendant's Information: (NOTE: To provide information about more defendants than there is room for here, use this format on another sheet of paper.) Name of Defendant 1:____________________________________________________________ Title (If applicable):______________________________________________________________ Address of Defendant:____________________________________________________________ ____________________________________________________________________________________ Name of Defendant 2:____________________________________________________________ Title (If applicable):______________________________________________________________ Address of Defendant:____________________________________________________________ ____________________________________________________________________________________ Name of Defendant 3:____________________________________________________________ Title (If applicable):______________________________________________________________ Address of Defendant:____________________________________________________________ ____________________________________________________________________________________ Name of Defendant 4:____________________________________________________________ Title (If applicable):______________________________________________________________ Address of Defendant:____________________________________________________________ ____________________________________________________________________________________ 2

II. JURISDICTION Jurisdiction is invoked pursuant to 28 U.S.C. § 1331. (If you wish to assert jurisdiction under additional statutes, you may fill in the title and section below.) ___________ U.S.C. § ______________ ___________ U.S.C. § ______________

III. BASIS FOR CLAIMS Check any Applicable Item(s): ________ Complaint Under the Civil Rights Act, 42 U.S.C. § 1983 (state, county, or municipal defendants) Complaint under Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971) (federal defendants) Other (cite statute, if known)___________________________________________ IV. CLAIMS BRIEFLY state the background of your case.

________

________

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Claim I: (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:

Claim III:

V. PREVIOUS LAWSUITS AND ADMINISTRATIVE RELIEF 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 "V. PREVIOUS LAWSUITS AND ADMINISTRATIVE RELIEF.") 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?) ___________________________________________________________ Issues raised: ______________________________________________________________ Approximate date of filing lawsuit:____________________________ Approximate date of disposition: ______________________________

d. e. f. 2.

I have previously exhausted available administrative remedies regarding the events or acts complained of in Part II of this complaint. __________ Yes ________ No If your answer is "Yes", briefly describe how relief was sought and the result: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ VI. PREVIOUSLY DISMISSED ACTIONS OR APPEALS

1.

If you are proceeding under 28. U.S.C. §1915, please list each civil action or appeal you have brought in any court of the United States while you were incarcerated or detained in any facility, that was dismissed as frivolous, malicious, or for failure to state a claim upon which relief may be granted. Please describe each civil action or appeal. If there is more than one civil action or appeal, describe the additional civil actions or appeals using this same format on a blank sheet which you should label "VI. PREVIOUSLY DISMISSED ACTIONS OR APPEALS." a. Parties to previous lawsuit: Plaintiff(s):______________________________________________________________ Defendant(s): ___________________________________________________________ b. c. Name and location of court and docket number:_________________________________ Grounds for dismissal: ( ) frivolous ( ) malicious ( ) failure to state a claim upon which relief may be granted

d. e.

Approximate date of filing lawsuit: ___________________________________________ Approximate date of disposition:_____________________________________________

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VII. REQUEST FOR RELIEF I request the following relief:

_______________________________________ Original signature of attorney (if any) Date:_______________________________

___________________________________

Plaintiff's Original Signature

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 accurate. Executed at _________________________ on ________________________. (location) (date)

___________________________________

Plaintiff's Original Signature

Plaintiff demands a trial by jury. _______ Yes ______ No

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