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INSTRUCTIONS FOR FILING A CIVIL RIGHTS COMPLAINT Attached is a complaint form for filing an action under 42 U.S.C. § 1983. Observe the following instructions for completing the complaint: 1. Caption: It is very important, if possible, that you state the first and last name of each defendant and badge number, if appropriate. You are required to furnish the correct name and address of each person so that service of process upon each defendant can be made. 2. Contents: The form should be fully completed. It can be typewritten or handwritten. It must be legible. If you need more space to answer a question, attach a separate sheet of 8 ½ by 11 paper to your complaint. You are required to state facts, such as the date and location of the events. You need not make legal arguments or cite to cases. The complaint must have an original (not photocopied) signature by each plaintiff. The complaint need not be notarized. 3. Copies: You must send the Court the original complaint and two exact copies (a complete set of three). You should keep another copy for your records. Copies can be xeroxed, handwritten or typewritten, but all copies must be identical to the original. 4. Fee: The filing fee is $350, payable to the Clerk of the Court, USDC, EDNY by certified check, bank check, personal check, money order or cash (if paying in person). If the filing fee is paid, the U.S. Marshal will not be directed to serve the defendants and plaintiff will be responsible for service of process on defendants. Service of the summons and complaint can be made by anyone over the age of 18 who is not a party to the action. See Fed. R. Civ. P. 4. 5. Inability to Pay the Fee: If you cannot pay the fee, you may apply to the Court to proceed in forma pauperis (IFP) pursuant to 28 U.S.C § 1915 by completing the attached form. If there is more than one plaintiff, each plaintiff must provide a separate declaration in support of the request to proceed in forma pauperis. If you are a prisoner, you must also complete the attached Prisoner Authorization form. When you have completed the forms, mail the original and 2 copies to the United States District Court, EDNY, 225 Cadman Plaza East, Brooklyn, NY 11201 Attention: Pro Se Office or on Long Island to: Clerk of United States District Court, EDNY, 100 Federal Plaza, Central Islip, NY 11722. This instruction page need not be copied or submitted. Remember to keep a copy of the completed complaint for your records.

rev. 4/06

CIVIL RIGHTS COMPLAINT 42 U.S.C. § 1983 UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK ----------------------------------------------------x _____________________________, Full name of plaintiff/prisoner ID# Plaintiff, -against_____________________________ _____________________________ _____________________________ Enter full names of defendants [Make sure those listed above are identical to those listed in Part III.] Defendants. ----------------------------------------------------x I. Previous Lawsuits: A. 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 ( ) If your answer to A is yes, describe each lawsuit in the space below (If there is more than one lawsuit, describe the additional lawsuits on another piece of paper, using the same outline.) 1. Parties to this previous lawsuit: Plaintiffs: ________________________________ ________________________________ ________________________________ ________________________________ JURY DEMAND YES______ NO ______

B.

Defendants:

2. Court (if federal court, name the district; if state court, name the county) __________________________________________________

3. Docket Number: __________________________________ 1 4. Name of the Judge to whom case was assigned: _______________

5. Disposition: (for example: Was the case dismissed? Was it appealed? Is it still pending?) ________________________________________________________ 6. Approximate date of filing lawsuit: _________________________ 7. Approximate date of disposition: ___________________________ II. Place of Present Confinement: ___________________________________________ A. Is there a prisoner grievance procedure in this institution? Yes ( ) No ( ) B. Did you present the facts relating to your complaint in the prisoner grievance procedure? Yes ( ) No ( ) C. If your answer is YES, 1. What steps did you take? _________________________________ ________________________________________________________ ________________________________________________________ 2. What was the result? ____________________________________ ________________________________________________________ D. If your answer is NO, explain why not ____________________________ ______________________________________________________________ E. If there is no prison grievance procedure in the institution, did you complain to prison authorities? Yes ( ) No ( ) F. If your answer is YES, 1. What steps did you take? _________________________________ ________________________________________________________ ________________________________________________________ 2. What was the result? ____________________________________ ________________________________________________________

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III.

Parties: (In item A below, place your name in the first blank and place your present address in the second blank. Do the same for additional plaintiffs, if any.)

A. Name of plaintiff ___________________________________________ Address ______________________________________________________

(In item B below, place the full name and address of each defendant)

B. List all defendants' names and the addresses at which each defendant may be served. Plaintiff must provide the address for each defendant named. Defendant No. 1 ___________________________________________ ___________________________________________ ___________________________________________

Defendant No. 2

___________________________________________ ___________________________________________ ___________________________________________

Defendant No. 3

___________________________________________ ___________________________________________ ___________________________________________

Defendant No. 4

___________________________________________ ___________________________________________ ___________________________________________

Defendant No. 5

___________________________________________ ___________________________________________ ___________________________________________

[Make sure that the defendants listed above are identical to those listed in the caption on page 1].

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IV.

Statement of Claim:

(State briefly and concisely, the facts of your case. Include the date(s) of the event(s) alleged as well as the location where the events occurred. Include the names of each defendant and state how each person named was involved in the event you are claiming violated your rights. You need not give any legal arguments or cite to cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate paragraph. You may use additional 8 ½ by 11 sheets of paper as necessary.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

IV.A

If you are claiming injuries as a result of the events you are complaining about, describe your injuries and state what medical treatment you required. Was medical treatment received? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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V.

Relief:

State what relief you are seeking if you prevail on your complaint. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________.

I declare under penalty of perjury that on __________________, I delivered this (Date) complaint to prison authorities to be mailed to the United States District Court for the Eastern District of New York.

Signed this ________ day of ____________________, 20___. I declare under penalty of perjury that the foregoing is true and correct.

___________________________________
Signature of Plaintiff __________________________________________ Name of Prison Facility __________________________________________ __________________________________________ __________________________________________ Address __________________________________________ Prisoner ID#

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