Free Pro Se Forms Federal Prisoner - South Carolina

UNITED STATES DISTRICT COURT DISTRICT OF SOUTH CAROLINA

FORMS FOR FILING CASES PRO SE (Representing Yourself) Federal Prisoner
Revised October 3, 2007

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF SOUTH CAROLINA
__________________________________________________________ ) ) [Enter the full name of the plaintiff in this action] ) ) ) v. ) __________________________________________________________ ) ) __________________________________________________________ ) ) __________________________________________________________ ) ) __________________________________________________________ ) ) __________________________________________________________ ) Enter above the full name(s) of defendant(s) in this action

Civil Action No. ___________________________ (to be assigned by Clerk)

COMPLAINT Federal Prisoner

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 related to your imprisonment? Yes_______ No_______ B. If your answer to A is Yes, describe the 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: Plaintiff: __________________________________________________________________________________

Defendant(s): _______________________________________________________________________________ 2. Court: _____________________________________________________________________________________ (If federal court, name the district; if state court, name the county) Docket Number: _____________________________________________________________________________ Name(s) of Judge(s) to whom case was assigned: ___________________________________________________ Disposition: ________________________________________________________________________________ (For example, was the case dismissed? Appealed? Pending?)

3. 4. 5.

6. 7.

Approximate date of filing lawsuit: ______________________________________________________________ Approximate date of disposition: ________________________________________________________________

II. PLACE OF PRESENT CONFINEMENT A. Name of Prison/Jail/Institution: ____________________________________________________________________ ___________________________

B. What are the issues that you are attempting to litigate in the above-captioned case?

_______________________________________________________________________________________________ C. (1) Is there a prisoner grievance procedure in this institution? Yes_______ No_______ Yes_______ No_______

(2) Did you file a grievance concerning the claims you are raising in this matter? When____________________________

Grievance Number (if available) ____________________________

D. Have you received a final agency/departmental/institutional answer or determination concerning this matter (i.e., your grievance)? Yes_______ No_______ E. When was the final agency/departmental/institutional answer or determination received by you? _________________ If possible, please attach a copy of your grievance and a copy of the highest level decision concerning your grievance that you have received. F. If there is no prison grievance procedures in this institution, did you complain to prison, jail, or institutional authorities? Yes_______

No_______

G. If your answer is YES: 1. 2. What steps did you take? ______________________________________________________________________ What was the result? _________________________________________________________________________

III. PARTIES In Item A below, place your name, inmate number, and address in the space provided. Do the same for additional plaintiffs, if any. A. Name of Plaintiff:________________________________________________ Inmate No.: ____________________

Address: ________________________________________________________________________________________ In Item B below, place the full name of the defendant, his official position, and place of employment in the space provided. Use Item C for additional defendants, if any. B. Name of Defendant:______________________________________________ Position: _______________________

Place of Employment: _____________________________________________________________________________ C. Additional Defendants (provide the same information for each defendant as listed in Item B above): ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

IV. STATEMENT OF CLAIM

State here, as briefly as possible, the facts of your case. Describe how each defendant is involved. Include also the names of other persons involved, dates, and places. Do not give any legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate paragraph. Use as much space as you need. Attach an extra sheet if necessary. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

IV. STATEMENT OF CLAIM - continued. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________________________________________________

V. RELIEF. State briefly and exactly what you want the court to do for you. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

I declare under penalty of perjury that the foregoing is true and correct.
Signed this _________________ day of ___________________________________________________, 20__________.

____________________________________________________________ Signature of Plaintiff

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF SOUTH CAROLINA INFORMATION FOR PRISONERS FILING AN APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT (FORM AO 240) AND A FINANCIAL CERTIFICATE WHICH ARE REQUIRED TO PROCEED IN FORMA PAUPERIS IN CIVIL RIGHTS ACTIONS/BIVENS ACTIONS Effective April 9, 2006, the costs for filing a lawsuit is $350.00 and must be paid when the complaint is filed. If you are unable to pay the filing fee, you may file an Application to Proceed without Prepayment of Fees and Affidavit (Form AO 240) which is a request to proceed in forma pauperis. All prisoners, other than pre-trial detainees, also must file a completed Financial Certificate. A. General Information About Form AO 240: 1. The Form AO 240 (form attached) is a request for the court to determine whether you qualify for proceeding in a case without prepayment of the full filing fee as established in 28 U.S.C. § 1914 (currently $350.00). Payment of the full filing fee is required by 28 U.S.C. § 1915. In order for your Form AO 240 to be considered by the United States District Court for the District of South Carolina, it must be typewritten or legibly handwritten. All information must be clearly and concisely written in the appropriate space on the form. Your original signature must be on the form you submit to the Court. 2. When your Form AO 240 is completed, you should mail THE ORIGINAL Form AO 240 along with the additional items listed in the Checklist, which is enclosed, to: Clerk, U.S. District Court District of South Carolina 901 Richland Street Columbia, South Carolina 29201 If you are submitting your Form AO 240 and/or Financial Certificate in response to an order of this Court, you must put your case number on the documents and mail the ORIGINAL documents to the address provided in the order. 3. It is important to realize that even though a plaintiff may be permitted to proceed without prepayment of the filing fee, if the plaintiff fails to prevail in the case, costs may be taxed against him or her when the case is ended, as specified in 28 U.S.C. §§ 1915(f) and 1920; and Flint v. Haynes, 651 F. 2d 970 (4th Cir. 1981). NOTE TO PRISONER (other than pretrial detainee): Filing the FINANCIAL CERTIFICATE is required under 28 U.S.C. § 1915(a)(2) in order for you to proceed in forma pauperis. THE FORM AO 240 IS NOT COMPLETE AND WILL NOT BE CONSIDERED BY THE COURT UNLESS THE FINANCIAL CERTIFICATE HAS BEEN PROPERLY COMPLETED. B. General Information About the Financial Certificate: 1. A Financial Certificate (form attached) must accompany your Form AO 240. The Financial Certificate must be signed by you and be completed and signed by the appropriate officer having authority to review and calculate financial information in relation to your inmate trust account. If you are detained in a

county jail, city jail or local detention center, you do not have to submit the Financial Certificate.
2. If you do not meet the requirements for paying the filing fee in installments, then the full filing fee found in 28 U.S.C. § 1914 must accompany the civil rights complaint. If you cannot afford to pay the full filing fee, but you have sufficient funds (as calculated according to the Prison Litigation Reform Act) to pay an installment payment, then you must pay the first installment of the filing fee, as computed on the Financial Certificate, at the time you file your complaint. 3. A properly completed financial certificate is required for the court to consider the Form AO 240 submitted by a prisoner in the South Carolina Department of Corrections or Federal Bureau of Prisons. DO NOT submit your own affidavit instead of the Financial Certificate, or your case may be delayed. The obligation to pay the filing fee in a case arises out of the filing of a case. See 28 U.S.C. § 1915. 4. To obtain a financial certificate disclosing how much money you have credited to your account(s) with the institution in which you are confined, you must sign your name and write your prisoner number (if you have one) on the lines provided at the top of the Financial Certificate (form attached). You should then submit only that page to the division/department that keeps the records of how much money you have in your account(s). (The name of that division/department varies depending on where you are being held, for example, "institutional services" - "accounting", etc.) Someone in that division/department will complete the remainder of the Financial Certificate and return it to you. It is then ready to be submitted to the court with the civil rights/Bivens complaint. You must submit the original Financial Certificate, not a copy. 5. The Financial Certificate must be current and signed by the authorized officer of the penal institution within six (6) months of its submission to the court. The Form AO 240 with the completed financial certificate, the accompanying civil rights complaint and all other papers listed on the Checklist must be mailed to the Clerk's Office TOGETHER. 6. When you receive the completed financial certificate, it will show whether you have sufficient funds to pay the full filing fee or whether you qualify for proceeding by paying the filing fee in installments. This determination is based on how much money is currently on deposit in your institutional account(s) and how much money to which you had access over the past six (6) months. Below is a line-by-line description of the information provided on the Financial Certificate: (a) The first line shows the average monthly deposits to your prison trust account. (b) The second line shows the average monthly balance in your prison trust account for the immediate past six (6) full months. (c) The third line shows the total amount of money to which you have access in your institutional account(s) as of the date that the financial certificate was completed. Money that is not readily accessible is not included in this total; the institution or agency confining you may have a policy which requires that a certain minimum balance be maintained, and so the amount shown on the third line would only include an amount in excess of the required minimum. (d) The fourth line shows the initial installment payment of the filing fee.

CHECKLIST
When a civil rights case from a state, local or federal prisoner is received, the Office of the Clerk of Court shall determine whether the case is in proper form. The term "in proper form" means that the Clerk of Court has received: (1) A complaint with your original signature on the appropriate form or in a form substantially similar; (2) The full filing fee or an Application to Proceed without Prepayment of Fees and Affidavit (Form AO 240) requesting to proceed in forma pauperis; (3) A Financial Certificate form (from all prisoners except pre-trial detainees) completed by the plaintiff and by an officer or employee of the institution where the plaintiff is confined or of the prison system in which the plaintiff is confined; (4) A separate Form USM-285 for each defendant sued if the plaintiff is proceeding in forma pauperis (Note that the plaintiff must provide information sufficient to identify the defendant(s) on the Form(s) USM-285. The United States Marshal cannot serve a defendant that is not properly identified, and defendants that are not served may be dismissed as parties to a case.); (5) A separate summons form for each defendant sued or one summons listing all defendants and their addresses; If you need additional space on any of the forms, you may submit additional pages. The plaintiff must use letter-sized paper [8 x 11 inch] and write or type text on one side of a sheet of paper only. Do not write or type on both sides of any sheet of paper. Do not write to the edge of the paper, but maintain one inch margins on the top, bottom and sides of each paper submitted.

Note to Inmate: If you are detained in a county jail, city jail, or local detention center, you do not have to submit the Financial Certificate. You must submit the Form AO 240.

OAO 240 (Rev. 10/03)

UNITED STATES DISTRICT COURT
District of

Plaintiff V.

APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT

CASE NUMBER:

Defendant
I,

declare that I am the (check appropriate box) G other

G petitioner/plaintiff/movant

in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? G Yes G No (If "No," go to Part 2)

If "Yes," state the place of your incarceration Are you employed at the institution? Do you receive any payment from the institution?

Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months' transactions. 2. Are you currently employed? a. G Yes G No

If the answer is "Yes," state the amount of your take-home salary or wages and pay period and give the name and address of your employer.

b.

If the answer is "No," state the date of your last employment, the amount of your take-home salary or wages and pay period and the name and address of your last employer.

3.

In the past 12 twelve months have you received any money from any of the following sources? a. b. c. d. e. f. Business, profession or other self-employment Rent payments, interest or dividends Pensions, annuities or life insurance payments Disability or workers compensation payments Gifts or inheritances Any other sources G G G G G G Yes Yes Yes Yes Yes Yes G G G G G G No No No No No No

If the answer to any of the above is "Yes," describe, on the following page, each source of money and state the amount received and what you expect you will continue to receive.

AO 240 Reverse (Rev. 10/03)

4.

Do you have any cash or checking or savings accounts? If "Yes," state the total amount.

G Yes

G No

5.

Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other thing of value? G Yes G No If "Yes," describe the property and state its value.

6.

List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support.

I declare under penalty of perjury that the above information is true and correct.

Date

Signature of Applicant

NOTICE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account.

FINANCIAL CERTIFICATE FOR THE DISTRICT OF SOUTH CAROLINA
(for use in § 1983, Bivens, and non-habeas civil actions filed by prisoners)

I request that an authorized officer of the institution in which I am confined, or other person designated to review financial information in relation to inmate trust funds, complete this Certificate. If I have insufficient funds in my account that prohibit me from paying the full filing fee required by 28 U.S.C. § 1914 (currently $350.00), I will send with my complaint an initial installment payment, required by 28 U.S.C. § 1915, equal to the amount calculated and entered on line four by the authorized officer signing this form. I recognize that by filing this case, I am required to pay the full filing fee (or the remaining unpaid portion of the filing fee by installments if necessary) under 28 U.S.C. § 1915(b) even though I am requesting to proceed in forma pauperis. I authorize and consent to collection of the filing fee in accordance with 28 U.S.C. § 1915 until the filing fee is paid in full. ___________________________________ INMATE (PRISONER) NUMBER ___________________________________ PLACE OF CONFINEMENT

INMATE NAME (PRINTED) _____________________________________ INMATE SIGNATURE , , (1) Average monthly deposits to the inmate's account..........................$ (2) Average monthly balance in the inmate's account calculated for the prior six months period. ................................$ (3) Current Balance ....................................$ (4) Initial Installment Payment (Take 20 percent of the greater of lines 1 or 2)........................................$

, ,

I hereby certify that as of this date, the above financial information is accurate for the above named inmate. __________________________________ Date

Authorized Officer's Signature

Authorized Officer's Name and Title