Willard Edward Davis, Jr. v. Ryan Thornell, et al.

Opinion

1 NH 2 WO 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Willard Edward Davis, Jr., No. CV-25-00054-PHX-JAT (JFM) 10 Plaintiff, 11 v. ORDER 12 Ryan Thornell, et al., 13 Defendants.

15 On January 8, 2025, Plaintiff Willard Edward Davis, Jr., who is confined in the 16 Arizona State Prison Complex-Eyman, filed a pro se civil rights Complaint pursuant to 42 17 U.S.C. § 1983 and an Application to Proceed In Forma Pauperis. In a May 15, 2025 Order, 18 the Court granted the Application to Proceed and dismissed the Complaint because Plaintiff 19 had failed to state a claim. The Court gave Plaintiff 30 days to file an amended complaint 20 that cured the deficiencies identified in the Order. 21 On May 30, 2025, Plaintiff filed a First Amended Complaint. In a September 23, 22 2025 Order, the Court dismissed the First Amended Complaint because Plaintiff had failed 23 to state a claim. The Court gave Plaintiff 30 days to file a second amended complaint that 24 cured the deficiencies identified in the Order. 25 On October 22, 2025, Plaintiff filed a Second Amended Complaint (Doc. 19). He 26 later filed a Motion to Subpoena Photos of Injuries (Doc. 21) and a Motion for Status (Doc. 27 23). The Court will deny Plaintiff’s Motion to Subpoena, grant in part Plaintiff’s Motion 28 for Status, and dismiss the Second Amended Complaint with leave to amend. 1 I. Statutory Screening of Prisoner Complaints 2 The Court is required to screen complaints brought by prisoners seeking relief 3 against a governmental entity or an officer or an employee of a governmental entity. 28 4 U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff 5 has raised claims that are legally frivolous or malicious, fail to state a claim upon which 6 relief may be granted, or seek monetary relief from a defendant who is immune from such 7 relief. 28 U.S.C. § 1915A(b)(1)–(2). 8 A pleading must contain a “short and plain statement of the claim showing that the 9 pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 does 10 not demand detailed factual allegations, “it demands more than an unadorned, the- 11 defendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678 12 (2009). “Threadbare recitals of the elements of a cause of action, supported by mere 13 conclusory statements, do not suffice.” Id. 14 “[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a 15 claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly, 16 550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual content 17 that allows the court to draw the reasonable inference that the defendant is liable for the 18 misconduct alleged.” Id. “Determining whether a complaint states a plausible claim for 19 relief [is] . . . a context-specific task that requires the reviewing court to draw on its judicial 20 experience and common sense.” Id. at 679. Thus, although a plaintiff’s specific factual 21 allegations may be consistent with a constitutional claim, a court must assess whether there 22 are other “more likely explanations” for a defendant’s conduct. Id. at 681. 23 But as the United States Court of Appeals for the Ninth Circuit has instructed, courts 24 must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 342 25 (9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less stringent 26 standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. Pardus, 551 27 U.S. 89, 94 (2007) (per curiam)). 28 1 If the Court determines that a pleading could be cured by the allegation of other 2 facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal 3 of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) (en banc). The 4 Court will dismiss Plaintiff’s Second Amended Complaint for failure to state a claim, but 5 because it may possibly be amended to state a claim, the Court will dismiss it with leave 6 to amend. 7 II. Second Amended Complaint 8 In his two-count Complaint, Plaintiff alleges Eighth Amendment claims for failure 9 to protect and sues Arizona Department of Corrections, Rehabilitation and Reentry 10 (ADCRR) Director Ryan Thornell and Deputy Warden Fajardo. Plaintiff seeks injunctive 11 relief and $2.5 million in damages. 12 In Count One, Plaintiff alleges that in November 2024, Defendants removed him 13 from a sex offender unit and placed him in a transition pod for severely mentally ill inmates. 14 He claims the general population inmates did a “roll call” and had “someone on the streets” 15 look up Plaintiff’s charges online. The next day, Plaintiff allegedly declined his two-hour 16 “out of cell” time, but some of the general population inmates “got the tower officer” to 17 open “3B502,” and the inmates ran in and assaulted Plaintiff. According to Plaintiff, there 18 we no floor officers present at the time but two officers arrived in the pod after the assault 19 to find Plaintiff with his door open and a laceration on his head. The officers initiated an 20 Incident Command System and took him to medical to be evaluated. Plaintiff claims a 21 Naphcare nurse took photos of his laceration and wounds and used steri-strips on his 22 wounds. Plaintiff asserts he was then taken to another overflow unit. Allegedly, the 23 incident was recorded on camera. 24 Plaintiff claims he suffers from post-traumatic stress disorder (PTSD), nightmares, 25 and “lives in fear on a daily basis that he will be killed [by general population inmates] for 26 being a sex offender”. 27 In Count Two, Plaintiff claims that following the assault, “he asked verbally and in 28 writing on his [tablet],” to be transferred out of the unit, “but [his] requests fell on deaf 1 ears.”1 Plaintiff stayed in the same over-flow unit for two weeks and was then returned to 2 the same pod of general population inmates who assaulted him. He claims he keeps 3 “getting threatened, extorted, and spit [on]” and is in constant fear for his life. Plaintiff 4 claims Defendants’ failure to place him in protective segregation or a sex offender unit has 5 caused him PTSD and nightmares. 6 III. Failure to State a Claim 7 To prevail in a § 1983 claim, a plaintiff must show that (1) acts by the defendants 8 (2) under color of state law (3) deprived him of federal rights, privileges or immunities and 9 (4) caused him damage. Thornton v. City of St. Helens, 425 F.3d 1158, 1163-64 (9th Cir. 10 2005) (quoting Shoshone-Bannock Tribes v. Idaho Fish & Game Comm’n, 42 F.3d 1278, 11 1284 (9th Cir. 1994)). In addition, a plaintiff must allege that he suffered a specific 12 injury as a result of the conduct of a particular defendant and he must allege an 13 affirmative link between the injury and the conduct of that defendant. Rizzo v. Goode, 423 14 U.S. 362, 371-72, 377 (1976) (emphasis added). 15 The Supreme Court has held that mere negligent failure to protect an inmate from 16 another inmate is not actionable under § 1983. Davidson v. Cannon, 474 U.S. 344 (1986). 17 A prison official violates the Eighth Amendment in failing to protect one inmate from 18 another only when two conditions are met. First, the alleged constitutional deprivation 19 must be, objectively, “sufficiently serious;” the official’s act or omission must result in the 20 denial of “the minimal civilized measure of life=s necessities.” Farmer v. Brennan, 511 21 U.S. 825, 834 (1994). Second, the prison official must have a “sufficiently culpable state 22 of mind,” i.e., he must act with deliberate indifference to inmate health or safety. Id. In 23 defining “deliberate indifference” in this context, the Supreme Court has imposed a 24 subjective test: “the official must both be aware of the facts from which the inference could 25 be drawn that a substantial risk of serious harm exists, and he must also draw the 26 inference.” Id. at 839 (emphasis supplied). 27

28 1 Plaintiff alleges these requests can be subpoenaed from ADCRR and Securus Technologies. 1 Plaintiff does not allege Defendants Thornell or Fajardo were actually aware of a 2 threat to Plaintiff’s safety from other inmates and failed to take action to protect him; 3 indeed he alleges no facts regarding these Defendants. Accordingly, Plaintiff has failed to 4 state a claim against these Defendants. 5 IV. Leave to Amend 6 For the foregoing reasons, the Court will dismiss Plaintiff’s Second Amended 7 Complaint for failure to state a claim upon which relief may be granted. Within 30 days, 8 Plaintiff may submit a third amended complaint to cure the deficiencies outlined above. 9 The Clerk of Court will mail Plaintiff a court-approved form to use for filing a third 10 amended complaint. If Plaintiff fails to use the court-approved form, the Court may strike 11 the third amended complaint and dismiss this action without further notice to Plaintiff. 12 Plaintiff must clearly designate on the face of the document that it is the “Third 13 Amended Complaint.” The third amended complaint must be retyped or rewritten in its 14 entirety on the court-approved form and may not incorporate any part of the original 15 Complaint or prior Amended Complaints by reference. Plaintiff may include only one 16 claim per count. 17 A third amended complaint supersedes the original Complaint and prior Amended 18 Complaints. Ferdik v. Bonzelet, 963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios 19 v. Richard Feiner & Co., 896 F.2d 1542, 1546 (9th Cir. 1990). After amendment, the Court 20 will treat the original Complaint and prior Amended Complaints as nonexistent. Ferdik, 21 963 F.2d at 1262. Any cause of action that was raised in the original Complaint or prior 22 Amended Complaints and that was voluntarily dismissed or was dismissed without 23 prejudice is waived if it is not alleged in a third amended complaint. Lacey v. Maricopa 24 County, 693 F.3d 896, 928 (9th Cir. 2012) (en banc). 25 If Plaintiff files an amended complaint, Plaintiff must write short, plain statements 26 telling the Court: (1) the constitutional right Plaintiff believes was violated; (2) the name 27 of the Defendant who violated the right; (3) exactly what that Defendant did or failed to 28 do; (4) how the action or inaction of that Defendant is connected to the violation of 1 Plaintiff’s constitutional right; and (5) what specific injury Plaintiff suffered because of 2 that Defendant’s conduct. See Rizzo v. Goode, 423 U.S. at 371-72, 377 (1976). 3 Plaintiff must repeat this process for each person he names as a Defendant. If 4 Plaintiff fails to affirmatively link the conduct of each named Defendant with the specific 5 injury suffered by Plaintiff, the allegations against that Defendant will be dismissed for 6 failure to state a claim. Conclusory allegations that a Defendant or group of 7 Defendants has violated a constitutional right are not acceptable and will be 8 dismissed. 9 If Plaintiff does not know the names of the person(s) who violated his constitutional 10 rights, he may refer to each person by a fictitious name, for example, John Doe 1, John 11 Doe 2, and so on. Plaintiff must then allege when, where, and how each Doe defendant 12 violated his constitutional rights. 13 V. Motion to Subpoena Photos of Injuries 14 Plaintiff seeks to subpoena photos of the injuries he sustained on December 7, 2025. 15 (Doc. 21.) Plaintiff’s Motion is essentially a request for discovery and is premature 16 because the Court has not yet ordered service on Defendants. The Court will deny the 17 Motion. If Plaintiff files an amended complaint and the Court determines an answer is 18 required, the Court will order the United States Marshal to serve Defendants. After 19 Defendants have filed an answer, the Court will issue a scheduling order that sets the time 20 for the parties to conduct discovery. 21 VI. Motion for Status 22 In his Motion, Petitioner seeks a status update of this case (Doc. 23). The Court will 23 grant the Motion to the extent that this Order informs him of the status of the case. In all 24 other respects, the Motion will be denied. 25 VII. Warnings 26 A. Release 27 If Plaintiff is released while this case remains pending, and the filing fee has not 28 been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court 1 that he intends to pay the unpaid balance of his filing fee within 120 days of his release or 2 (2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may 3 result in dismissal of this action. 4 B. Address Changes 5 Plaintiff must file and serve a notice of a change of address in accordance with Rule 6 83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion for other 7 relief with a notice of change of address. Failure to comply may result in dismissal of this 8 action. 9 C. Possible “Strike” 10 Because the Second Amended Complaint has been dismissed for failure to state a 11 claim, if Plaintiff fails to file a third amended complaint correcting the deficiencies 12 identified in this Order, the dismissal may count as a “strike” under the “3-strikes” 13 provision of 28 U.S.C. § 1915(g). Under the 3-strikes provision, a prisoner may not bring 14 a civil action or appeal a civil judgment in forma pauperis under 28 U.S.C. § 1915 “if the 15 prisoner has, on 3 or more prior occasions, while incarcerated or detained in any facility, 16 brought an action or appeal in a court of the United States that was dismissed on the 17 grounds that it is frivolous, malicious, or fails to state a claim upon which relief may be 18 granted, unless the prisoner is under imminent danger of serious physical injury.” 28 19 U.S.C. § 1915(g). 20 D. Possible Dismissal 21 If Plaintiff fails to timely comply with every provision of this Order, including these 22 warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d 23 at 1260-61 (a district court may dismiss an action for failure to comply with any order of 24 the Court). 25 . . . . 26 . . . . 27 . . . . 28 . . . . 1| ITIS ORDERED: 2 Plaintiff’s Motion to Subpoena Photos of Injuries (Doc. 21) is denied. 3 (2) Plaintiff's Motion for Status (Doc. 23) is granted to the extent that this Order informs him of the status of this case. In all other respects, the Motion is denied. 5 (3) |The Second Amended Complaint (Doc. 19) is dismissed for failure to state 6) aclaim. Plaintiff has 30 days from the date this Order is filed to file a third amended 7 | complaint in compliance with this Order. 8 (4) — If Plaintiff fails to file a third amended complaint within 30 days, the Clerk 9 of Court must, without further notice, enter a judgment of dismissal of this action with 10 | prejudice that states that the dismissal may count as a “strike” under 28 U.S.C. § 1915(g) 11.) and deny any pending unrelated motions as moot. 12 (5) The Clerk of Court must mail Plaintiff a court-approved form for filing a civil 13 | rights complaint by a prisoner. 14 Dated this 28th day of May, 2026. 15

17 18 _ James A. Teil Org Senior United States District Judge 19 20 21 22 23 24 25 26 27 28

Ic

Instructions for a Prisoner Filing a Civil Rights Complaint in the United States District Court for the District of Arizona

1. Who May Use This Form. The civil rights complaint form is designed to help incarcerated persons prepare a complaint seeking relief for a violation of their federal civil rights. These complaints typically concern, but are not limited to, conditions of confinement. This form should not be used to challenge your conviction or sentence. If you want to challenge a state conviction or sentence, you should file a petition under 28 U.S.C. ' 2254 for a writ of habeas corpus by a person in state custody. If you want to challenge a federal conviction or sentence, you should file a motion under 28 U.S.C. § 2255 to vacate sentence in the federal court that entered the judgment. 2. The Form. Local Rule of Civil Procedure (LRCiv) 3.4 provides that complaints by incarcerated persons must be filed on the court-approved form. The form must be typed or neatly handwritten. The form must be completely filled in to the extent applicable. All questions must be answered clearly and concisely in the appropriate space on the form. If needed, you may attach additional pages, but no more than fifteen additional pages, of standard letter-sized paper. You must identify which part of the complaint is being continued and number all pages. If you do not fill out the form properly, you will be asked to submit additional or corrected information, which may delay the processing of your action. You do not need to cite law. 3. Your Signature. You must tell the truth and sign the form. If you make a false statement of a material fact, you may be prosecuted for perjury. 4. The Filing and Administrative Fees. The total fees for this action are $405.00 ($350.00 filing fee plus $55.00 administrative fee). If you are unable to immediately pay the fees, you may request leave to proceed in forma pauperis. Please review the “Information for Prisoners Seeking Leave to Proceed with a (Non-Habeas) Civil Action in Federal Court In Forma Pauperis Pursuant to 28 U.S.C. ' 1915” for additional instructions. 5. Original and Judge=s Copy. You must send an original plus one copy of your complaint and of any other documents submitted to the Court. You must send one additional copy to the Court if you wish to have a file-stamped copy of the document returned to you. All copies must be identical to the original. Copies may be legibly handwritten. This section does not apply to inmates housed at an Arizona Department of Corrections facility that participates in electronic filing. 6. Where to File. You should file your complaint in the division where you were confined when your rights were allegedly violated. See LRCiv 5.1(a) and 77.1(a). If you were confined in Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. If you were confined in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott Division. If you were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file in the Tucson Division. Unless you are an inmate housed at an Arizona Department of Corrections facility that participates in electronic filing, mail the original and one copy of the complaint with the $405 filing and administrative fees or the application to proceed in forma pauperis to:

1 Revised 11/6/24 Phoenix & Prescott Divisions: OR Tucson Division: U.S. District Court Clerk U.S. District Court Clerk U.S. Courthouse, Suite 130 U.S. Courthouse, Suite 1500 401 West Washington Street, SPC 10 405 West Congress Street Phoenix, Arizona 85003-2119 Tucson, Arizona 85701-5010

7. Change of Address. You must immediately notify the Court and the defendants in writing of any change in your mailing address. Failure to notify the Court of any change in your mailing address may result in the dismissal of your case.

8. Certificate of Service. You must furnish the defendants with a copy of any document you submit to the Court (except the initial complaint and application to proceed in forma pauperis). Each original document (except the initial complaint and application to proceed in forma pauperis) must include a certificate of service on the last page of the document stating the date a copy of the document was mailed to the defendants and the address to which it was mailed. See Fed. R. Civ. P. 5(a), (d). Any document received by the Court that does not include a certificate of service may be stricken. This section does not apply to inmates housed at an Arizona Department of Corrections facility that participates in electronic filing. A certificate of service should be in the following form:

I hereby certify that a copy of the foregoing document was mailed this (month, day, year) to: Name: Address: Attorney for Defendant(s)

(Signature)

9. Amended Complaint. If you need to change any of the information in the initial complaint, you must file an amended complaint. The amended complaint must be written on the court- approved civil rights complaint form. You may file one amended complaint without leave (permission) of Court within 21 days after serving it or within 21 days after any defendant has filed an answer, whichever is earlier. See Fed. R. Civ. P. 15(a). Thereafter, you must file a motion for leave to amend and lodge (submit) a proposed amended complaint. LRCiv 15.1. In addition, an amended complaint may not incorporate by reference any part of your prior complaint. LRCiv 15.1(a)(2). Any allegations or defendants not included in the amended complaint are considered dismissed. All amended complaints are subject to screening under the Prison Litigation Reform Act; screening your amendment will take additional processing time.

10. Exhibits. You should not submit exhibits with the complaint or amended complaint. Instead, the relevant information should be paraphrased. You should keep the exhibits to use to support or oppose a motion to dismiss, a motion for summary judgment, or at trial.

11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff of any judge. The only appropriate way to communicate with the Court is by filing a written pleading or motion.

2 12. Completing the Civil Rights Complaint Form.

HEADING: 1. Your Name. Print your name, prison or inmate number, and institutional mailing address on the lines provided.

2. Defendants. If there are four or fewer defendants, print the name of each. If you name more than four defendants, print the name of the first defendant on the first line, write the words “and others” on the second line, and attach an additional page listing the names of all of the defendants. Insert the additional page after page 1 and number it “1- A” at the bottom.

3. Jury Demand. If you want a jury trial, you must write “JURY TRIAL DEMANDED” in the space below “CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do so may result in the loss of the right to a jury trial. A jury trial is not available if you are seeking only injunctive relief.

Part A. JURISDICTION: 1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. ' 1983 for state, county, or city defendants; “Bivens v. Six Unknown Federal Narcotics Agents” for federal defendants; or “other.” If you mark “other,” identify the source of that authority.

2. Location. Identify the institution and city where the alleged violation of your rights occurred.

3. Defendants. Print all of the requested information about each of the defendants in the spaces provided. If you are naming more than four defendants, you must provide the necessary information about each additional defendant on separate pages labeled “2-A,” “2-B,” etc., at the bottom. Insert the additional page(s) immediately behind page 2.

Part B. PREVIOUS LAWSUITS: You must identify any other lawsuit you have filed in either state or federal court while you were a prisoner. Print all of the requested information about each lawsuit in the spaces provided. If you have filed more than three lawsuits, you must provide the necessary information about each additional lawsuit on a separate page. Label the page(s) as “2-A,” “2-B,” etc., at the bottom of the page and insert the additional page(s) immediately behind page 2.

Part C. CAUSE OF ACTION: You must identify what rights each defendant violated. The form provides space to allege three separate counts (one violation per count). If you are alleging more than three counts, you must provide the necessary information about each additional count on a separate page. Number the additional pages “5-A,” “5-B,” etc., and insert them immediately behind page 5. Remember that you are limited to a total of fifteen additional pages.

3 1. Counts. You must identify which civil right was violated. You may allege the violation of only one civil right per count.

2. Issue Involved. Check the box that most closely identifies the issue involved in your claim. You may check only one box per count. If you check the box marked “Other,” you must identify the specific issue involved.

3. Supporting Facts. After you have identified which civil right was violated, you must state the supporting facts. Be as specific as possible. You must state what each individual defendant did to violate your rights. If there is more than one defendant, you must identify which defendant did what act. You also should state the date(s) on which the act(s) occurred, if possible.

4. Injury. State precisely how you were injured by the alleged violation of your rights.

5. Administrative Remedies. You must exhaust any available administrative remedies before you file a civil rights complaint. See 42 U.S.C. § 1997e. Consequently, you should disclose whether you have exhausted the inmate grievance procedures or administrative appeals for each count in your complaint. If the grievance procedures were not available for any of your counts, fully explain why on the lines provided.

Part D. REQUEST FOR RELIEF: Print the relief you are seeking in the space provided.

SIGNATURE: You must sign your name and print the date you signed the complaint. Failure to sign the complaint will delay the processing of your action. Unless you are an attorney, you may not bring an action on behalf of anyone but yourself.

FINAL NOTE

You should follow these instructions carefully. Failure to do so may result in your complaint being stricken or dismissed. All questions must be answered concisely in the proper space on the form. If you need more space, you may attach no more than fifteen additional pages. But the form must be completely filled in to the extent applicable. If you attach additional pages, be sure to identify which section of the complaint is being continued and number the pages.

4 ___________________________________________ Name and Prisoner/Booking Number ___________________________________________ Place of Confinement ___________________________________________ Mailing Address ___________________________________________ City, State, Zip Code (Failure to notify the Court of your change of address may result in dismissal of this action.)

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ARIZONA

_________________________________________ , (Full Name of Plaintiff)

Plaintiff, v. CASE NO. __________________________________ (To be supplied by the Clerk) (1) _______________________________________ , (Full Name of Defendant) CIVIL RIGHTS COMPLAINT (2) _______________________________________ , BY A PRISONER

(3) _______________________________________ , G Original Complaint (4) _______________________________________ , G First Amended Complaint G Second Amended Complaint Defendant(s).

G Check if there are additional Defendants and attach page 1-A listing them.

A. JURISDICTION

1. This Court has jurisdiction over this action pursuant to: G 28 U.S.C. § 1343(a); 42 U.S.C. § 1983 G 28 U.S.C. § 1331; Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971). G Other: .

2. Institution/city where violation occurred: .

550/555 B. DEFENDANTS

1. Name of first Defendant: . The first Defendant is employed as: ______________________________________________ at_______________________________________. (Position and Title) (Institution)

2. Name of second Defendant: . The second Defendant is employed as: as: ______________________________________________ at_______________________________________. (Position and Title) (Institution)

3. Name of third Defendant: . The third Defendant is employed as: ______________________________________________ at_______________________________________. (Position and Title) (Institution)

4. Name of fourth Defendant: . The fourth Defendant is employed as: ______________________________________________ at_______________________________________. (Position and Title) (Institution)

If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page.

C. PREVIOUS LAWSUITS

1. Have you filed any other lawsuits while you were a prisoner? G Yes G No

2. If yes, how many lawsuits have you filed? . Describe the previous lawsuits:

a. First prior lawsuit: 1. Parties: v. 2. Court and case number: . 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) .

b. Second prior lawsuit: 1. Parties: v. 2. Court and case number: . 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) .

c. Third prior lawsuit: 1. Parties: v. 2. Court and case number: . 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) .

If you filed more than three lawsuits, answer the questions listed above for each additional lawsuit on a separate page. D. CAUSE OF ACTION

COUNT I 1. State the constitutional or other federal civil right that was violated: .

2. Count I. Identify the issue involved. Check only one. State additional issues in separate counts. G Basic necessities G Mail G Access to the court G Medical care G Disciplinary proceedings G Property G Exercise of religion G Retaliation G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count I. Describe exactly what each Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

5. Administrative Remedies: a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? G Yes G No b. Did you submit a request for administrative relief on Count I? G Yes G No c. Did you appeal your request for relief on Count I to the highest level? G Yes G No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. .

3 COUNT II 1. State the constitutional or other federal civil right that was violated: .

2. Count II. Identify the issue involved. Check only one. State additional issues in separate counts. G Basic necessities G Mail G Access to the court G Medical care G Disciplinary proceedings G Property G Exercise of religion G Retaliation G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count II. Describe exactly what each Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

5. Administrative Remedies. a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? G Yes G No b. Did you submit a request for administrative relief on Count II? G Yes G No c. Did you appeal your request for relief on Count II to the highest level? G Yes G No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. .

4 COUNT III 1. State the constitutional or other federal civil right that was violated: .

2. Count III. Identify the issue involved. Check only one. State additional issues in separate counts. G Basic necessities G Mail G Access to the court G Medical care G Disciplinary proceedings G Property G Exercise of religion G Retaliation G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count III. Describe exactly what each Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

5. Administrative Remedies. a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? G Yes G No b. Did you submit a request for administrative relief on Count III? G Yes G No c. Did you appeal your request for relief on Count III to the highest level? G Yes G No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. .

If you assert more than three Counts, answer the questions listed above for each additional Count on a separate page.

5 E. REQUEST FOR RELIEF

State the relief you are seeking:

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

Executed on DATE SIGNATURE OF PLAINTIFF

___________________________________________ (Name and title of paralegal, legal assistant, or other person who helped prepare this complaint)

___________________________________________ (Signature of attorney, if any)

___________________________________________ (Attorney=s address & telephone number)

ADDITIONAL PAGES

All questions must be answered concisely in the proper space on the form. If you need more space, you may attach no more than fifteen additional pages. But the form must be completely filled in to the extent applicable. If you attach additional pages, be sure to identify which section of the complaint is being continued and number all pages.