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Derrick's Incarceration

ACTUAL BLANK IJR -- PETITION FOR JUDICIAL REVIEW
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ACTUAL BLANK IJR -- PETITION FOR JUDICIAL REVIEW
NINETEENTH JUDICIAL DISTRICT COURT

PARISH OF EAST BATON ROUGE

STATE OF LOUISIANA





__________________________ SUIT NUMBER:_________

(Enter above, the full name of the plaintiff

or plaintiffs in this action.)

VERSUS

__________________________ DIVISION:____________

__________________________

__________________________

(Enter above, the full name of the defendant

or defendants in this action.)





PETITION FOR JUDICIAL REVIEW

I. Administrative Remedy Action

A. Did you present the facts relating to your complaint in the prisoner's

grievance procedure?

Yes ( ) No ( )

B. If your answer is YES, what is the number assigned to the prisoner's

grievance? Note: (List only one)

ARP No. _______________________________

Disciplinary Board Appeal No. _________________________

Property Claim No. ____________________________________

C. If your answer is YES:

1. What steps did you take? _____________________________________

____________________________________

2. What was your result? ____________________________________

____________________________________



II Previous Lawsuits



A. Have you begun any other lawsuits in state or federal court dealing with

the same facts involved in this action or the same administrative grievance?

YES ( ) NO ( )

B. If your answer is YES, describe each lawsuit in the space below. (If there

is more than one lawsuit, describe the additional lawsuits on another piece of

paper, using the same outline.)



1. Parties to this previous lawsuit:

Plaintiff(s): ___________________________, DOC # _________________________

___________________________, DOC # _________________________

Defendant(s): __________________________________________________________

__________________________________________________________



2. Court (If Federal Court, name the District; if State Court, name

the Parish):

_________________________________________________________________

3. Docket number: _________________________________________________

4. Name of Judge to whom case was assigned: ______________________

5. Disposition (for example: Was the case dismissed? Was it

appealed? Is it still pending?)

_________________________________________________________________

6. Approximate date of filing lawsuit: _______________________________

7. Approximate date of disposition: _________________________________



III. Parties

A. Plaintiff (Fill in your name, DOC #, and present address)

Name: ____________________________, DOC # ___________________________________

Address: _____________________________________________________________________

(In item B below, place the full name of the defendant in the first blank, their

official position in the second blank, and their place of employment in the third

blank. Use item C for the names, positions, and places of employment of any

additional defendants.)

B. Defendant ___________________________, is employed as _________________

___________________________ at _________________________________________

C. Additional defendants:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

IV. Statement of the Claim

State here as briefly as possible why you believe the final decision by the

Department in the administrative remedy action you listed in Part I, above, is

incorrect. (See La. R.S. 15:1177 and R.S. 49:964).



V. Relief

State briefly exactly what you want the court to do for you. Make no legal

arguments. Cite no cases or statutes.



VI. RULE XII -- 19TH JDC RULES -- YOU MUST ATTACH TO THIS PETITION A COPY

OF THE FINAL DECISION BY THE DEPARTMENT.



Signed this ______________ day of ___________________________, 20_____.



_________________________________________DOC # _______________________

_________________________________________DOC # _______________________

_________________________________________DOC # _______________________

(Signature of plaintiff or plaintiffs)



VERIFICATION

STATE OF LOUISIANA

PARISH OF __________________________________



______________________________, DOC # _______________________, being first duly

sworn, under oath says: that he is the plaintiff in this action and knows the

content of the above petition; that it is the true of is knowledge, except as to

those matters that are stated in it on his information and belief, and as to those

matters he believes them to be true.





_________________________________________

(Signature of plaintiff)

Subscribed and sworn to me this _________ day of __________________, 20____.

__________________________________

(Notary Public or other person

authorized to administer an oath)

- SERVICE INFORMATION REQUIRED -

The Plaintiff must provide full names and addresses for service below on all

defendants.



INMATE ASSISTANCE CERTIFICATION



I. Were you assisted by any inmate in the preparation of, or research for this

lawsuit?

YES ( ) NO ( )



II. If your answer is Yes, the inmate who assisted must print and sign his name,

along with this DOC #, certifying that he supports the plaintiff's claims herein. If

none, print "NONE".



_______________________________ _______________________________

Inmate DOC # & Location (print) Inmate (Sign) & Date







______________________________________

VS. NUMBER: DIVISION:

______________________________________



19TH JUDICIAL DISTRICT COURT

PARISH OF EAST BATON ROUGE

STATE OF LOUISIANA





SERVICE INFORMATION SHEET



Plaintiff must provide full names and street addresses for service on

all defendants:



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LSA -- R.S. 49:964

LSA -- R.S. 15:1177

I CAN VOTE WHEN I AM RELEASED AND I WILL!!!!!