Free Complaint - District Court of Delaware - Delaware

Case 1:06-cv-00264-GMS

Document 2

Filed 04/24/2006

Page 1 of 5

(Rev. 5/05)

FORM T O BE USED BY A PRISONER IN FILING A COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. 51983 IN THE UNITED STATES DISTRICT COURT FOR T H E DISTRICT O F DELAWARE

(Name of plaintiff)

(Inmate Number)

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(Complete ~ d h r e s s with zip code)

(Name of Plaintift)

(Inmate Number)
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(Case Number)
( to be assigned by U.S. District Court)

(Complete Address with zip code) (Each named party must be listed, and all names must be printed or typed. Use additional sheets if needed)
VS.

:

CIVIL COMPLAINT

Jury Trial Requested

(3)
(Names of Defendants) (Each named party must be listed, and all names must be printed or typed. Use additional sheets if needed) I. A. PREVIOUS LAWSUITS

APR 2 4 2006

DISTRICT 0: !?EMWARE and If you have filed any other lawsuits in federal court while a prisoner, please list the capt~on case ~ U L I including year, as well as the name of the judicial officer to whom it was assigned:

Case 1:06-cv-00264-GMS

Document 2

Filed 04/24/2006

Page 2 of 5

11.

EXHAUSTION OF ADMINISTRATIVE REMEDIES

In order to proceed in federal court. you must fully exhaust any available administrative remedies as to each ground on which you request action.
A.

Is there a prisoner grievance procedure available at your present institution? Have you full, exhausted your available administrative remedies regarding each of your present claims.! A ' e s *No If your answer to "B" is b :

B.
C.

I . What steps did you take?

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2. What was the result'.'

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If your answer to "B" is No, explain why not:

Ill.

DEFENDANTS (in order listed on the caption)
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Name of first defendant:

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Mailing address with zip code:

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(2) Name of second defendant: Employed as

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Mailing address with zip code:

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(3) Name of third defendant:

Employed as Mailing address with zip code:

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(List any additional defendants, their employment, and addresses with zip codes, on extra sheets if necessary)

Case 1:06-cv-00264-GMS

Document 2

Filed 04/24/2006

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IV. STATEIMENT OF CLAIM

(State as briefly as possible the facts of your case. Describe how each defendant is involved, including dates and places. Do not give any legal arguments or cite any cases o r statutes. Attach no more than three extra sheets of paper if necessary.)

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V.

RELIEF

(State briefly exactly what you want the Court to do for you. Make no legal arguments. Cite no cases or statutes.)
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Case 1:06-cv-00264-GMS

Document 2

Filed 04/24/2006

Page 4 of 5

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

Signed this

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day of

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, j ~ i g & t u r e Plaintiff I ) o

Case 1:06-cv-00264-GMS

Document 2

Filed 04/24/2006

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