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Pro Se 15 (Rev. 12/16) Complaint for Violation of Civil Rights (Non-Prisoner) |
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United
States District Court |
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for the |
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) ) ) ) ) ) ) ) ) ) ) ) ) ) ) |
Case No. |
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(to be filled in by the Clerk�s Office) |
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Plaintiff(s) (Write the full name of each plaintiff who is filing this complaint.
If the names of all the plaintiffs cannot fit in the space above, please
write �see attached� in the space and attach an additional page with the full
list of names.) -v- |
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Jury Trial:� (check one) |
Yes |
No |
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Defendant(s) (Write the full name of each defendant who is being sued.� If the names of all the defendants cannot
fit in the space above, please write �see attached� in the space and attach
an additional page with the full list of names.� Do not include addresses here.) |
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COMPLAINT FOR VIOLATION OF CIVIL RIGHTS |
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(Non-Prisoner Complaint) |
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NOTICE Federal Rules of Civil
Procedure 5.2 addresses the privacy and security
concerns resulting from public access to electronic court files.� Under this rule, papers filed with the
court should not contain: an
individual�s full social security number or full birth date; the full name of
a person known to be a minor; or a complete financial account number.� A filing may include only: the last four digits of a social security number; the year
of an individual�s birth; a minor�s initials; and the last four digits of a
financial account number. Except as noted in this
form, plaintiff need not send exhibits, affidavits, grievance or witness
statements, or any other materials to the Clerk�s Office with this complaint. In order
for
your complaint to be filed, it must be accompanied by the filing fee or an
application to proceed in forma pauperis. |
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I.��������� The Parties to This
Complaint ����������� ����������� A.������� The Plaintiff(s) |
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����������������������� Provide the information below for each
plaintiff named in the complaint.�
Attach additional pages if ����������������������� needed. |
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������������������������������ Name |
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������������������������������ Address |
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City |
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State |
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Zip Code |
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������������������������������ County |
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������������������������������ Telephone Number |
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������������������������������ E-Mail Address |
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����������� ����������� B.�������� The Defendant(s) ����������������������� Provide the information below for each
defendant named in the complaint, whether the defendant is an ����������������������� individual, a government agency, an
organization, or a corporation.� For an
individual defendant, ����������������������� include the person�s job or title (if
known) and check whether you are bringing this complaint against ����������������������� them in their individual capacity or
official capacity, or both.� Attach
additional pages if needed. ����������������������� |
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����������������������� Defendant No. 1 |
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������������������������������ Name |
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������������������������������ Job or Title (if known) |
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������������������������������ Address |
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City |
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State |
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Zip Code |
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������������������������������ County |
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������������������������������ Telephone Number |
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������������������������������ E-Mail Address (if known) |
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Individual capacity |
Official capacity |
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����������������������� Defendant No. 2 |
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������������������������������ Name |
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������������������������������ Job or Title (if known) |
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������������������������������ Address |
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City |
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State |
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Zip Code |
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������������������������������ County |
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������������������������������ Telephone Number |
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������������������������������ E-Mail Address (if known) |
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����������� |
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Individual capacity |
Official capacity |
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����������������������� Defendant No. 3 |
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������������������������������ Name |
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������������������������������ Job or Title (if known) |
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������������������������������ Address ����������������������� |
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City |
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State |
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Zip Code |
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������������������������������ County |
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������������������������������ Telephone Number |
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������������������������������ E-Mail Address (if known) |
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Individual capacity |
Official capacity |
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����������������������� Defendant No. 4 |
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������������������������������ Name |
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������������������������������ Job or Title (if known) |
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������������������������������ Address |
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City |
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State |
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Zip Code |
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������������������������������ County |
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������������������������������ Telephone Number |
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������������������������������ E-Mail Address (if known) |
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Individual capacity |
Official capacity |
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II.������� Basis for
Jurisdiction ����������� Under 42 U.S.C. � 1983, you may sue state or local
officials for the "deprivation of any rights, privileges, or ����������� immunities secured by the Constitution and [federal
laws]."� Under Bivens v. Six Unknown Named Agents of ����������� Federal Bureau of
Narcotics, 403 U.S. 388 (1971), you may sue federal officials for the violation
of certain ����������� constitutional rights. ����������� A.������� Are you bringing suit against (check all that apply): |
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Federal officials (a Bivens claim) |
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State or local officials
(a � 1983 claim) |
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����������� B.�������� Section
1983 allows claims alleging the "deprivation of any rights, privileges,
or immunities secured by ����������������������� the Constitution and [federal
laws]."� 42 U.S.C. � 1983.� If you are suing under section 1983, what ����������������������� federal constitutional or statutory
right(s) do you claim is/are being violated by state or local officials? |
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����������� C.�������� Plaintiffs
suing under Bivens may only recover
for the violation of certain constitutional rights.� If you ����������������������� are suing under Bivens, what constitutional right(s) do you claim is/are being
violated by federal ����������������������� officials? |
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����������� D.������� Section
1983 allows defendants to be found liable only when they have acted
"under color of any ����������� ����������� statute,
ordinance, regulation, custom, or usage, of any State or Territory or the
District of Columbia."� ����������������������� 42 U.S.C. � 1983.� If you are suing under section 1983,
explain how each defendant acted under color ����������������������� of state or local law.� If you are suing under Bivens, explain how each defendant acted under color of ����������������������� federal law.� Attach additional pages if needed. |
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III.���� Statement of Claim ���������� State as briefly as possible the facts of your
case.� Describe how each defendant was
personally involved in the ���������� alleged wrongful action, along with the dates and
locations of all relevant events.� You
may wish to include ���������� further details such as the names of other persons involved in the events giving
rise to your claims.� Do not cite ���������� any cases or statutes.�
If more than one claim is asserted, number each claim and write a
short and plain ��� ���������� statement of each claim in a separate paragraph.� Attach additional pages if needed. |
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���������� A.��������� Where
did the events giving rise to your claim(s) occur? |
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���������� B.��������� What
date and approximate time did the events giving rise to your claim(s) occur? |
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���������� C.��������� What
are the facts underlying your claim(s)?�
(For example:� What happened to you?� Who did what? � ��������������������� Was anyone else involved?� Who else saw what happened?) |
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IV.���� Injuries ���������� If you sustained injuries related to the events alleged
above, describe your injuries and state what medical ���������� treatment, if any, you required and did or did not
receive. |
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V.������ Relief ���������� State briefly what you want the court to do for you.
Make no legal arguments. Do not cite any cases or statutes. ���������� If
requesting money damages, include
the amounts of any actual damages and/or punitive
damages claimed for ���������� the acts alleged.�
Explain the basis for these claims. |
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VI.���� Certification and
Closing � ���������� Under Federal Rule of Civil Procedure 11, by signing
below, I certify to the best of my knowledge, information, ���������� and belief that this complaint: (1) is not being
presented for an improper purpose, such as to harass, cause ���������� unnecessary delay, or needlessly increase the cost of
litigation; (2) is supported by existing law or by a ���������� nonfrivolous argument for extending, modifying, or
reversing existing law; (3) the factual contentions have ���������� evidentiary support or, if specifically
so identified, will likely have evidentiary support after a reasonable ���������� opportunity for further investigation or discovery; and
(4) the complaint otherwise complies with the ���������� requirements of Rule 11. |
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���������� A.��������� For Parties Without an Attorney ����������������������� I agree to provide the Clerk�s Office with
any changes to my address where case-related papers may be ����������������������� served.�
I understand that my failure to keep a current address on file with
the Clerk�s Office may result ����������������������� in the dismissal of my case. |
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����������������������� Date of signing: |
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����������������������� Signature of Plaintiff |
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����������������������� Printed Name of Plaintiff |
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���������� B.��������� For Attorneys |
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����������������������� Date of signing: |
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����������������������� Signature of Attorney |
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����������������������� Printed Name of Attorney |
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����������������������� Bar Number |
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����������������������� Name of Law Firm |
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����������������������� Address |
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City |
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State |
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Zip Code |
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����������������������� Telephone Number |
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����������������������� E-mail Address |
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