UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK AARON DEMOND SMALLS, Plaintiff, -against- 25-CV-775 (KMW) KIRBY PSYCHIATRIC CENTER; SOUTH BEACH PSYCHIATRIC CENTER; ORDER TO AMEND MANHATTAN SUPREME COURT PSYCHIATRIC CENTER, Defendants. KIMBA M. WOOD, United States District Judge: Plaintiff, proceeding pro se, is currently detained at Kirby Psychiatric Center (“Kirby”). Plaintiff brings this action under 42 U.S.C. § 1983 asserting claims against Kirby, South Beach Psychiatric Center (“South Beach”), and “Manhattan Supreme Court Psychiatric Center,”1 regarding his involuntary hospitalization at Kirby.2 Plaintiff also asserts claims regarding his involuntary medication at Kirby and South Beach. By Order dated January 31, 2025, the Court granted Plaintiff’s request to proceed in forma pauperis (“IFP”), that is, without prepayment of fees.3 (ECF No. 8.) For the reasons set forth below, the Court grants Plaintiff 60 days, from the date of this order, to file an amended complaint.
1 The Court understands this to be the Manhattan Forensic Psychiatric Evaluation Court Clinic (“Manhattan Forensic”). 2 Plaintiff filed this action in the Eastern District of New York, and that court transferred the matter to this district because the underlying events occurred at Manhattan Forensic and Kirby, both located in New York, New York. 3 Plaintiff filed this action when he was detained on Rikers Island. He therefore is not exempt from paying the full filing fee, even though he has been granted permission to proceed IFP. See 28 U.S.C. § 1915(b)(1). STANDARD OF REVIEW The Prison Litigation Reform Act requires federal courts to screen complaints brought by prisoners who seek relief against a governmental entity or an officer or employee of a governmental entity. See 28 U.S.C. § 1915A(a). The Court must dismiss a prisoner’s IFP
complaint, or any portion of the complaint, that is frivolous or malicious, fails to state a claim upon which relief may be granted, or seeks monetary relief from a defendant who is immune from such relief. 28 U.S.C. §§ 1915(e)(2)(B), 1915A(b); see Abbas v. Dixon, 480 F.3d 636, 639 (2d Cir. 2007). The Court also must dismiss a complaint if the court lacks subject matter jurisdiction over the claims raised. See Fed. R. Civ. P. 12(h)(3). Although the law mandates dismissal on any of these grounds, the Court is obligated to construe pro se pleadings liberally, Harris v. Mills, 572 F.3d 66, 72 (2d Cir. 2009), and to interpret them to raise the “strongest [claims] that they suggest,” Triestman v. Fed. Bureau of Prisons, 470 F.3d 471, 474 (2d Cir. 2006) (per curiam) (internal quotation marks and citations omitted) (emphasis in original).
BACKGROUND The following facts are drawn from the complaint.4 From February 2022 through December 2022, Plaintiff “was placed under a 730 evaluation under lies and corruption.” (ECF No. 1 at 3.) “[Defendant] Manhattan Supreme Psychiatric Center deemed me unfit for a grand larceny case which was dismissed.” (Id. at 4.) “[Defendant] Kirby Psychiatric Center forged
4 The Court quotes from the complaint verbatim. All spelling, grammar, and punctuation appear as in the complaint, unless noted otherwise. documents, stated I couldn’t answer basic political & legal question and states I was there 2008.” (Id.) Plaintiff “was placed in treatment over objection[.]” (Id.) “Dr. Magona,” who is not named as a defendant, “force[d] me to take anti-psychotic medications and held me down.” (Id.) Plaintiff “was then forced to South Beach psych.,” which is located on Staten Island, and “forced due to lies.” (Id.)
Plaintiff pleads facts in the injury section of the complaint indicating that he suffers “trauma, defamation of character, corruption.” (Id.) He seeks to have his “record cleared and $100 million dollars in damage[s].” (Id. at 5.) Plaintiff previously brought a lawsuit in this Court against two forensic psychiatrists who appear to be associated with Defendant Manhattan Forensic. See Smalls v. Cooper, No. 22-CV- 4115 (S.D.N.Y. June 21, 2022) (Swain, C.J.) (“Smalls I”). Plaintiff asserted claims against Amy Cooper, M.D., and Daniel S. Mundy, M.D., in connection with examinations and reports that they provided to the New York Supreme Court, which had ordered that Plaintiff be examined under N.Y. Crim. Proc. Law § 730.30. Plaintiff alleged that Dr. Cooper conducted a video
conference with Plaintiff on March 22, 2022, when Plaintiff did not have access to his hearing aids; Plaintiff claimed that because he could not hear Dr. Cooper, her evaluation was “illegal.” Smalls I, ECF No. 1 at 5. Plaintiff attached to his complaint reports from Dr. Cooper and Dr. Mundy, in which both doctors determined that Plaintiff was unfit to proceed to trial on the criminal charges against him. Id. at 19. The Court dismissed the claims brought against Dr. Cooper and Dr. Mundy under the doctrine of absolute, quasi-judicial immunity.
DISCUSSION This action concerns Plaintiff’s evaluation by psychiatrists associated with “Manhattan Supreme Psychiatric Center,” and his subsequent involuntary hospitalization and medication at Kirby and South Beach. However, Plaintiff cannot proceed against Defendants for the following reasons. First, Plaintiff cannot bring claims against Kirby and South Beach because, under the Eleventh Amendment, they are immune from liability for money damages. Second, Plaintiff does not state a claim against Manhattan Forensic, which is operated by
New York City Health + Hospitals (“H+H”). The Court dismisses these claims for failure to state a claim, with leave to replead. Third, to the extent Plaintiff seeks to bring claims against the individuals who determined that he should be involuntarily hospitalized at Kirby, he does not state facts suggesting that such individuals violated his rights. The Court therefore grants Plaintiff leave to amend such a claim. Fourth, to the extent Plaintiff brings claims against medical staff at Kirby and South Beach, who he alleges involuntarily medicated him, Plaintiff does not state any facts suggesting that such medical staff violated his rights. The Court grants Plaintiff leave to file an amended complaint against medical staff at Kirby that addresses the deficiencies identified in this Order.
The Court declines to grant Plaintiff leave to amend claims against medical staff at South Beach, without prejudice to his filing a new civil action in the Eastern District of New York. A. Claims Against Kirby and South Beach “[A]s a general rule, state governments may not be sued in federal court unless they have waived their Eleventh Amendment immunity, or unless Congress has abrogated the states’ Eleventh Amendment immunity.” Gollomp v. Spitzer, 568 F.3d 355, 366 (2d Cir. 2009) (internal quotation marks, alterations, and citation omitted.) “The immunity recognized by the Eleventh Amendment extends beyond the states themselves to state agents and state instrumentalities that are, effectively, arms of a state.” Id. (alteration and citation omitted.) New York State has not waived its Eleventh Amendment immunity to suit in federal court, and Congress did not abrogate the states’ immunity by enacting 42 U.S.C. § 1983. See Trotman v. Palisades Interstate Park Comm’n, 557 F.2d 35, 38-40 (2d Cir. 1977). Psychiatric centers operated by New York State’s Office of Mental Health (“OMH”) are state agencies that are immune from suit under the Eleventh Amendment. See, e.g., Al-Haj v. OMH State of N.Y., No. 18-CV-5505, 2019 WL 6831391, at *2 (S.D.N.Y. Aug. 5, 2019)
(Netburn, M.J.) (“Kirby is an agency of the State of New York, and its employees are ‘state officials’ for purposes of the Eleventh Amendment.”) (citation omitted), report and recommendation adopted sub nom., Al-Haj v. Weisner, No. 18-CV-5505, 2019 WL 4051478 (S.D.N.Y. Aug. 28, 2019) (Caproni, J.). Kirby and South Beach are both state agencies operated by OMH. Therefore, Plaintiff’s Section 1983 claims against them, seeking money damages, are barred by the Eleventh Amendment. Because these two psychiatric centers are immune from liability in this action, the Court dismisses the claims against Kirby and South Beach. See 28 U.S.C. § 1915(e)(2)(B)(iii). B. Claims Against Manhattan Forensic Plaintiff asserts claims against Manhattan Forensic, operated by H+H. The Court
therefore construes the complaint as asserting these claims against H+H and directs the Clerk of Court, under Rule 21 of the Federal Rules of Civil Procedure, to substitute H+H for Manhattan Forensic. The Court also directs the Clerk of Court to terminate “Manhattan Supreme Court Psychiatric Center” as a defendant in this action. H+H is a public benefit corporation that is created by state law and may be sued. See N.Y. Unconsol. Laws §§ 7384(1), 7385(1). When a plaintiff sues H+H under Section 1983, it is not enough for the plaintiff to allege that H+H’s employees or agents engaged in some wrongdoing. The plaintiff must show that H+H itself caused the violation of the plaintiff's rights. See Connick v. Thompson, 563 U.S. 51, 60 (2011) (“A municipality or other local government may be liable under this section [1983] if the governmental body itself ‘subjects’ a person to a deprivation of rights or ‘causes’ a person ‘to be subjected’ to such deprivation.” (quoting Monell v. Dep’t of Soc. Servs. of City of New York, 436 U.S. 658, 692 (1978))); Cash v. Cnty. of Erie, 654 F.3d 324, 333 (2d Cir. 2011). In other words, to state a claim against H+H under Section 1983, the plaintiff must allege facts showing (1) the existence of an H+H policy,
custom, or practice, and (2) that the policy, custom, or practice caused the violation of the plaintiff's constitutional rights. Jones v. Town of East Haven, 691 F.3d 72, 80-81 (2d Cir. 2012); see Bd. of Cnty. Comm’rs of Bryan Cnty. v. Brown, 520 U.S. 397, 403 (1997) (internal citations omitted); Rookard v. Health & Hosp. Corp., 710 F.2d 41, 45 (2d Cir. 1983) (applying standard for Section 1983 municipal liability to H+H). Plaintiff does not allege any facts suggesting that a policy, custom, or practice of H+H caused a violation of his federal constitutional rights. The Court therefore dismisses Plaintiff’s claims against H+H for failure to state claim on which relief may be granted, see 28 U.S.C. § 1915(e)(2)(B)(ii), with leave to replead this claim.
C. Claims Regarding Plaintiff’s Hospitalization and Treatment at Kirby Because Plaintiff names Kirby as a defendant, the Court construes the complaint as asserting claims against the individuals who determined, following Doctors Cooper’s and Mundy’s reports, that Plaintiff should be hospitalized. These claims arise under the procedural and substantive clauses of the Fourteenth Amendment. The Court also construes the complaint as asserting claims against the individuals at Kirby who determined that Plaintiff should be involuntarily medicated. The Court grants Plaintiff leave to file an amended complaint to assert these claims. Fourteenth Amendment The involuntary commitment and forcible psychiatric evaluation of an individual are both “‘massive curtailment[s] of liberty’ and [they] therefore cannot permissibly be accomplished without due process of law.” Rodriguez v. City of New York, 72 F.3d 1051, 1061 (2d Cir. 1995) (quoting Vitek v. Jones, 445 U.S. 480, 491 (1980) (“Commitment to a mental hospital produces a
massive curtailment of liberty.” (internal citations omitted))). To state a procedural due process claim regarding the involuntary commitment to a hospital, a plaintiff must allege facts suggesting“that they have a protected liberty interest in not being involuntarily committed to a psychiatric institution and that they were deprived of that interest without due process of law.” Bailey v. Pataki, 708 F.3d 391, 399 (2d Cir. 2013). To state a substantive due process claim, a plaintiff must allege facts suggesting that the state “involuntarily commit[ed] [a] non-dangerous mentally ill individual[].” Bolmer v. Oliveira, 594 F.3d 134, 142 (2d Cir. 2010)(citing O’Connor v. Donaldson, 422 U.S. 563, 575-76 (1975)). Where a plaintiff brings a substantive due process claim, he must allege facts suggesting that the nameddefendants’ “medical decisions represent such a substantial departure from accepted
professional judgment, practice, or standards that it demonstrates that they did not base their decision on such a judgment.” Youngberg v. Romeo, 457 U.S. 307, 323 (1982). Mental Hygiene Law New York Mental Hygiene Law provides procedures for the involuntary hospitalization of a person alleged to need such hospitalization: New York’s Mental Hygiene Law permits the involuntary commitment of a mentally ill person “upon the certificate of two examining physicians, accompanied by an application for the admission of such person.” N.Y. M.H.L. §9.27. The application for admission can be submitted by “the director of the hospital . . . in which the patient is hospitalized,” or “a qualified psychiatrist who is . . . treating such person for a mental illness in a facility licensed or operated by the [New York] office of mental health.” Id.§ 9.27(b)(6),(11). The director of the hospital cannot admit the patient until the patient is examined by a third member of the psychiatric staff other than the original examining physicians who confirms that the patient should be admitted. Id. § 9.27(e). Best v. Schneider, No. 12-CV-6142, 2014 WL 10417046, at *4 (E.D.N.Y. Sept. 10, 2014), report and recommendation adopted in part, rejected in part, 2015 WL 5567062 (E.D.N.Y. Sept. 21, 2015). Before involuntarily hospitalizing an individual, however, “the Constitution requires a finding that the mentally ill patient is a danger to himself or others.” Id. (citing O’Connor v. Donaldson, 422 U.S. 563, 572 (1975); Project Release v. Prevost, 722 F.2d 960, 973-74 (2d Cir. 1983) (finding that New York’s statutory scheme governing involuntary confinement met the requirements of due process)). The Second Circuit has held that the procedures set forth in the Mental Hygiene Law are facially constitutional.5 See Project Release, 722 F.2d 960, 971 (2d Cir. 1983). Therefore, when considering a due process challenge to an involuntary hospitalization in this Circuit, district courts must independently assess whether the state’s application of these procedures in the plaintiff’s particular case violated a constitutional right. See Charles W. v. Maul, 214 F.3d 350, 357 (2d Cir. 2000) (holding that the defendants did not violate the plaintiff’s due process rights
when they confined him for up to 72 hours to evaluate him and determine whether to initiate civil commitment proceedings); see, e.g., Best, 2015 WL 5567062, at *9 (in adopting report and recommendation, noting that the magistrate judge correctly found “that [the] [p]laintiff stated a
5 Section 9.31 of the Mental Hygiene Law requires that, [f]ollowing a commitment, the patient may request a post-deprivation hearing to determine the need for involuntary care and treatment. . . . The hearing must take place no later than five days after the court receives notice. . . . At the hearing, the court can examine and hear testimony from the alleged mentally ill person if it is appropriate. Best, 2014 WL 10417046, *5. claim for violation of his procedural due process rights on the basis of [the] [d]efendants’ failure to comply with the procedures proscribed by Article 9”). Plaintiff’s Claims Here, Plaintiff’s allegations—that “Kirby Psychiatric Center forged documents, stated I couldn’t answer basic political & legal question,” “placed [Plaintiff] in treatment over
objection,” and “force[d][Plaintiff]to take anti-psychotic medications and held me down” (ECF No. 1at 4)—do not state a constitutional claim. Plaintiff does not plead facts suggesting that any individual failed to follow the procedures set forth in New York’s Mental Hygiene Law when determiningthat he should be committed to Kirby and treated there. Although he disagrees with the assessment that he should be hospitalized, he does not state that individuals violated the procedures in the Mental Hygiene Law. Moreover, Plaintiff does not allege that, once hospitalized at Kirby, individuals violated his substantive due process rights by medicating him against his will. The Court therefore grants Plaintiff leave to name the individual defendants whom he asserts violated his rights by not complying with New York’s Mental Hygiene Law. D. Claims Regarding Plaintiff’s Hospitalization and Treatment at South Beach Plaintiff’s allegations regarding his hospitalization and treatment at South Beach also do
not state enough facts to suggest that any individual violated his rights. Although he states that he “was then forced to South Beach psych.& forced due to lies” (ECF No. 1at 4), he does not name individual defendants or state any conduct on the part of such individuals that suggest a violation of the Mental Hygiene Law. The Court declines to grant Plaintiff leave to amend this claim, however,because the proper venue for this claim is likely the United States District Court for the Eastern District of New York. Under the general venue provision, 28 U.S.C. § 1391(b), a civil action may be brought in (1) a judicial district in which any defendant resides, if all defendants are residents of the State in which the district is located; (2) a judicial district in which a substantial part of the events or omissions giving rise to the claim occurred . . . ; or (3) if there is no district in which an action may otherwise be brought as provided in this section, any judicial district in which any defendant is subject to the court’s personal jurisdiction with respect to such action. Venue for this claim appears to be proper in the Eastern District; South Beach is located on Staten Island, Richmond County, which falls within the Eastern District of New York. See 28 U.S.C. § 112. Under Section 1391(b)(1), venue is therefore proper in the Eastern District of New York. Venue is also proper in the Eastern District of New York under Section 1391(b)(2) because the events giving rise to this claim occurred in Richmond County. Thus, the Court dismisses the claims asserted against South Beach without prejudice to Plaintiff’s bringing a new civil action in the Eastern District of New York. Should Plaintiff reassert this claim here, the Court may, in the interests of justice, sever and transfer the claim to the Eastern District of New York. See 28 U.S.C. § 1404(a). E. Leave to Amend Is Granted Plaintiff proceeds in this matter without the benefit of an attorney. District courts generally grant a self-represented plaintiff an opportunity to amend a complaint to cure its defects, unless amendment would be futile. See Hill v. Curcione, 657 F.3d 116, 123-24 (2d Cir. 2011); Lucente v. Int’l Bus. Machs. Corp., 310 F.3d 243, 258 (2d Cir. 2002). Indeed, within the Second Circuit, “[a] pro se party should be granted leave to amend if ‘a liberal reading of the complaint gives any indication that a valid claim might be stated.’” Janakievski v. Exec. Dir., Rochester Psychiatric Ctr., 955 F.3d 314, 320 (2d Cir. 2020) (quoting Cuoco v. Moritsugu, 222 F.3d 99, 112 (2d Cir. 2000)). Because Plaintiff may be able to allege additional facts to state valid claims regarding his involuntary hospitalization and treatment at Kirby, the Court grants Plaintiff 60 days’ leave to amend his complaint to detail his claims. First, Plaintiff must name as the defendant(s) in the caption,® and in the “Statement of Claim”, those individuals who were allegedly involved in the deprivation of his federal rights. If Plaintiff does not know the name of a defendant, he may refer to that individual as “John Doe” or “Jane Doe” in both the caption and the body of the amended complaint.’ The naming of John Doe defendants, however, does nof toll the three-year statute of limitations period governing this action and Plaintiff shall be responsible for ascertaining the true identity of any “John Doe” defendants and amending his complaint to include the identity of any “John Doe” defendants before the statute of limitations period expires.® Second, in the “Statement of Claim” section of the amended complaint form, Plaintiff must provide a short and plain statement of the relevant facts supporting each claim against each defendant. Plaintiff must provide, if known, an address for any named defendant. Plaintiff should include all information in the amended complaint that Plaintiff wants the Court to consider in deciding whether the amended complaint states a claim for relief. That information should include: a) the names and titles of all relevant people; b) a description of all relevant events, including what each defendant did or failed to do, the approximate date and time of each event, and the general location where each event occurred;
® The caption is located on the front page of the complaint. Each individual defendant must be named in the caption. Plaintiff may attach additional pages if there is not enough space to list all defendants in the caption. If Plaintiff needs to attach an additional page to list all defendants, he should write “see attached list” on the first page of the Amended Complaint. Any defendants named in the caption must also be discussed in Plaintiffs statement of claim. 7 For example, a defendant may be identified as: “Kirby Psychiatrist John Doe #1 on duty August 31, 2022, during the 7-3 p.m. shift.” 8 Should Plaintiff seek to add a new claim or party after the statute of limitations period has expired, he must meet the requirements of Rule 15(c) of the Federal Rules of Civil Procedure.
a description of the injuries Plaintiff suffered; and the relief Plaintiff seeks, such as money damages, injunctive relief, or declaratory relief. Essentially, Plaintiff’s amended complaint shouldtell the Court: who violated his federally protected rights and how; when and where such violations occurred; and why Plaintiff is entitled to relief. Because Plaintiff’s amended complaint will completely replace, not supplement, the original complaint, any facts or claims that Plaintiff wants to include from the original complaint must be repeated in the amended complaint.
PRO SE LAW CLINC Plaintiff is advised that there is a pro se law clinic available to assist self-represented
parties in civil cases. The clinic may be able to provide Plaintiff with advice in connection with his case, including assisting him in amending his complaint. The pro se law clinic is run by a private organization called the City Bar Justice Center; it is not part of, or run by, the Court (and, among other things, therefore cannot accept filings on behalf of the Court, which must still be made by any self-represented party through the Pro Se Intake Unit). An informational flyer and a limited scope legal assistance retainer agreement are attached to this order.
CONCLUSION The Court grants Plaintiff leave to file an amended complaint that complies with the standards set forth above. Plaintiff must submit the amended complaint to this Court’s Pro Se
Intake Unitwithin sixty days of the date of this order, caption the document as an “Amended Complaint,” and label the document with docket number 25-CV-775(KMW). An Amended Civil Rights Complaint form is attached to this order. No summons will issue at this time. If Plaintiff does not file an amended complaint within the time allowed, and he cannot show good cause to excuse such failure, the complaint will be dismissed for failure to state a claim upon which relief may be granted. The Court dismisses from this action Kirby Psychiatric Center and South Beach
Psychiatric Center because these defendants are immune from liability under the Eleventh Amendment. See 28 U.S.C. § 1915(e)(2)(B)(iii). The Court directs the Clerk of Court to terminate these two defendants from this action. This dismissal is without prejudice to any claims Plaintiff may wish to pursue against individuals employed at South Beach, in the Eastern District of New York, regarding his alleged involuntary treatment at South Beach. The Court construes the complaint as asserting claims against Manhattan Supreme Psychiatric Center as asserted against New York City Health + Hospitals and directs the Clerk of Court, under Rule 21 of the Federal Rules of Civil Procedure, to substitute New York City Health + Hospitals for this defendant. The Court further directs the Clerk of Court to terminate
Manhattan Supreme Psychiatric Center from this action. An informational flyer and a limited scope legal assistance retainer agreement are attached to this order. The Court certifies under 28 U.S.C. § 1915(a)(3) that any appeal from this Order would not be taken in good faith, and therefore IFP status is denied for the purpose of an appeal. See Coppedge v. United States, 369 U.S. 438, 444-45 (1962). SO ORDERED. Dated: August 19, 2025 New York, New York
/s/ Kimba M. Wood KIMBA M. WOOD United States District Judge UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK
CV. Write the full name of each plaintiff. (Include case number if one has been assigned) AMENDED against: COMPLAINT (Prisoner) Do you want a jury trial? 0mNd—MN L1Yes LINo
Write the full name of each defendant. If you cannot fit the names of all of the defendants in the space provided, please write “see attached” in the space above and attach an additional sheet of paper with the full list of names. The names listed above must be identical to those contained in Section IV.
NOTICE The public can access electronic court files. For privacy and security reasons, papers filed with the court should therefore 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. See Federal Rule of Civil Procedure 5.2.
Rev. 5/20/16
I. LEGAL BASIS FOR CLAIM State below the federal legal basis for your claim, if known. This form is designed primarily for prisoners challenging the constitutionality of their conditions of confinement; those claims are often brought under 42 U.S.C. § 1983 (against state, county, or municipal defendants) or ina “Bivens” action (against federal defendants). L] Violation of my federal constitutional rights L] Other: Il. PLAINTIFF INFORMATION Each plaintiff must provide the following information. Attach additional pages if necessary.
First Name Middle Initial Last Name
State any other names (or different forms of your name) you have ever used, including any name you have used in previously filing a lawsuit.
Prisoner ID # (if you have previously been in another agency’s custody, please specify each agency and the ID number (such as your DIN or NYSID) under which you were held)
Current Place of Detention
Institutional Address
County, City State Zip Code II. PRISONER STATUS Indicate below whether you are a prisoner or other confined person: L] Pretrial detainee L] Civilly committed detainee L] Immigration detainee L] Convicted and sentenced prisoner L] Other:
IV. DEFENDANT INFORMATION To the best of your ability, provide the following information for each defendant. If the correct information is not provided, it could delay or prevent service of the complaint on the defendant. Make sure that the defendants listed below are identical to those listed in the caption. Attach additional pages as necessary. Defendant 1: First Name Last Name Shield #
Current Job Title (or other identifying information)
Current Work Address
County, City State Zip Code Defendant 2: First Name Last Name Shield #
County, City State Zip Code Defendant 3: First Name Last Name Shield #
County, City State Zip Code Defendant 4: First Name Last Name Shield #
County, City State Zip Code V. STATEMENT OF CLAIM Place(s) of occurrence:
Date(s) of occurrence: FACTS: State here briefly the FACTS that support your case. Describe what happened, how you were harmed, and how each defendant was personally involved in the alleged wrongful actions. Attach additional pages as necessary. INJURIES: If you were injured as a result of these actions, describe your injuries and what medical treatment, if any, you required and received.
VI. RELIEF State briefly what money damages or other relief you want the court to order. VII. PLAINTIFF’S CERTIFICATION AND WARNINGS By signing below, I certify to the best of my knowledge, information, and belief that: (1) the complaint is not being presented for an improper purpose (such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation); (2) the claims are supported by existing law or by a nonfrivolous argument to change 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 Federal Rule of Civil Procedure 11. I understand that if I file three or more cases while I am a prisoner that are dismissed as frivolous, malicious, or for failure to state a claim, I may be denied in forma pauperis status in future cases. I also understand that prisoners must exhaust administrative procedures before filing an action in federal court about prison conditions, 42 U.S.C. § 1997e(a), and that my case may be dismissed if I have not exhausted administrative remedies as required. I agree to provide the Clerk's Office with any changes to my address. 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. Each Plaintiff must sign and date the complaint. Attach additional pages if necessary. If seeking to proceed without prepayment of fees, each plaintiff must also submit an IFP application.
Dated Plaintiff’s Signature
Prison Address
County, City State Zip Code
Date on which I am delivering this complaint to prison authorities for mailing: (SERS □□□□ aak-mctolhaal-1gam idee (-1)'an DG)
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Please mail these completed forms to the City Bar Justice Center, Pro Se Legal Assistance Project, 40 Foley Square, LL22, New York, NY 10007.
CITY BAR CITY BAR JUSTICE CENTER JUSTICE CENTER SDNY Federal Pro Se Legal Assistance Project es Immigration status? (circle one) U.S. citizen (born in U.S.) Naturalized U.S. citizen Legal Permanent Resident (Born in: ) No lawful status Decline to answer Other:
Marital status? (circle one) Single Married Divorced Separated Widowed Decline to answer
Do you have a disability? (circle all that apply) No Mental health Vision Hearing Mobility Memory Homebound Decline to answer Other: What is your primary language? LGBTQ+? (circle one) Yes No Decline to answer Veteran?
Please mail these completed forms to the City Bar Justice Center, Pro Se Legal Assistance Project, 40 Foley Square, LL22, New York, NY 10007.