United States District Court
CENTRAL DISTRICT OF ILLINOIS
, Plaintiff vs. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )
Case No. (The case number will be assigned by the clerk)
(List the full name of ALL plaintiffs and defendants in the caption above. If you need more room, attach a separate caption page in the above format). COMPLAINT* Indicate below the federal legal basis for your complaint, if known. This form is designed primarily for pro se prisoners challenging the constitutionality of their conditions of confinement, claims which are often brought under 42 U.S.C. § 1983 (against state, county, or municipal defendants) or in a "Bivens" action (against federal defendants). However, 42 U.S.C. § 1983 and "Bivens" do not cover all prisoners' claims. Many prisoners' legal claims arise from other federal laws. Your particular claim may be based on different or additional sources of federal law. You may adapt this form to your claim or draft your own complaint. 42 U.S.C. §1983 (state, county or municipal defendants) Action under Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971)(federal defendants) Other federal law:
I. FEDERAL JURISDICTION
*Please refer to the instructions when filling out this complaint. Prisoners are not required to use this form or to answer all the questions on this form in order to file a complaint. This is not the form to file a habeas corpus petition.
Jurisdiction is based on 28 U.S.C. § 1331, a civil action arising under the United States Constitution or other federal law. (You may assert a different jurisdictional basis, if appropriate). II. PARTIES A. Plaintiff: Full Name: Prison Identification Number: Current address:
For additional plaintiffs, provide the information in the same format as above on a separate page. If there is more than one plaintiff, each plaintiff must sign the Complaint, and each plaintiff is responsible for paying his or her own complete, separate filing fee. B. Defendants Defendant #1: Full Name: Current Job Title: Current Work Address
Defendant #2: Full Name: Current Job Title: Current Work Address
Defendant #3: Full Name: Current Job Title:
Current Work Address
Defendant #4: Full Name: Current Job Title: Current Work Address
Defendant #5: Full Name: Current Job Title: Current Work Address
For additional defendants, provide the information in the same format as above on a separate page.
III. LITIGATION HISTORY The "three strikes rule" bars a prisoner from bringing a civil action or appeal in forma pauperis in federal court if that prisoner has "on 3 or more occasions, while incarcerated or detained in any facility, brought an action or appeal in a court of the United States that was dismissed on the grounds that it is frivolous, malicious, or fails to state a claim upon which relief may be granted, unless the prisoner is under imminent danger of serious physical injury." 28 U.S.C. § 1915(g). A. Have you brought any other lawsuits in state or federal court dealing with the same facts involved in this case? If yes, please describe Yes No
B. Have you brought any other lawsuits in federal court while incarcerated? Yes No
C. If your answer to B is yes, how many? _______ Describe the lawsuit(s) below. 3
1. Name of Case, Court and Docket Number ______________________________________________________________________________ 2. Basic claim made 3. Disposition (That is, how did the case end? Was the case dismissed? Was it appealed? Is it still pending?)
For additional cases, provide the above information in the same format on a separate page.
IV. EXHAUSTION OF ADMINISTRATIVE REMEDIES Prisoners must exhaust available administrative remedies before filing an action in federal court about prison conditions. 42 U.S.C. § 1997e(a). You are not required to allege or prove exhaustion of administrative remedies in the complaint. However, your case must be dismissed if the defendants show that you have not exhausted your administrative remedies, or if lack of exhaustion is clear from the complaint and its attachments. You may attach copies of materials relating to exhaustion, such as grievances, appeals, and official responses. These materials are not required to file a complaint, but they may assist the court in understanding your claim. A. Is there a grievance procedure available at your institution? Yes No
B. Have you filed a grievance concerning the facts relating to this complaint? Yes No
If your answer is no, explain why not
C. Is the grievance process completed?
V. STATEMENT OF CLAIM Place(s) of the occurrence 4
Date(s) of the occurrence State here briefly the FACTS that support your case. Describe what each defendant did to violate your federal rights. You do not need to give any legal arguments or cite cases or statutes. Number each claim in a separate paragraph. Unrelated claims should be raised in a separate civil action. THE COURT URGES YOU TO USE ONLY THE SPACE PROVIDED. Federal Rule of Civil Procedure 8(a) requires only a "short and plain statement" of your claim showing that you are entitled to relief. It is best to include only the basic, relevant facts, including dates, places, and names.
RELIEF REQUESTED (State what relief you want from the court.)
Signed this _______________ day of ___________________________ , 20_______.
( Signature of Plaintiff)
Name of Plaintiff:
Inmate Identification Number: