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Derrick's Incarceration

TITLE 42 U.S.C. 1983
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DOC RULES FOR ADULT INMATES
DOC -- DISCIPLINARY REPORT
DOC INCIDENT REPORT
INITIAL ARP FORM
FIRST STEP RESPONSE
SECOND STEP RESPONSE TO SECRETARY OF DOC
RISK REVIEW FORM
PAROLE
LOCATE INMATE
CLEMENCY APPLICATION / RULES
DOC HEADQUARTERS CONTACT NUMBERS
RISK REVIEW
FURLOUGHS / FUNERALS
PLACEMENT / TRANSFER OF INMATES
WORK RELEASE -- SELECTION -- JAIL / DOC
DOC INSTITUTIONS (PRISONS)
LOUISIANA ACLU COMPLAINT
COURT / JAIL LISTING BY PARISH
DOC ARP (GRIEVANCE) PROCESS
MOTIONS
TITLE 42 U.S.C. 1983
APPELLATE FORMA PAUPERIS
FORMA PAUPERIS
LAWS BEFORE INMATE FILING: CARP /PLRA
ACTUAL BLANK IJR -- PETITION FOR JUDICIAL REVIEW

________________________________



Full Name/Prisoner Number



________________________________



________________________________



________________________________



Complete Mailing Address



Plaintiff



IN THE UNITED STATES DISTRICT COURT



FOR THE ______________DISTRICT OF LOUISIANA



_______________________________________ )



Plaintiff, ) CASE NO. ______________



(Full name and prisoner number.) ) (To be supplied by the Court)



)



vs. )



) PRISONER CIVIL RIGHTS



_______________________________________ ) COMPLAINT



)



_______________________________________ )



Defendant(s), )



(Full name(s). Do not use et. al.) )



__________________________________________)



A. PARTIES



1. ______________________________________ is a citizen of ______________________



(Plaintiff) (State)



presently residing at ___________________________________________________________.



(Mailing address or place of confinement)



2. Defendant__________________________________ is a citizen of _________________



(Name of first defendant) (State)



whose address is _______________________________________________________________,



and who is employed as _________________________________________________________.



(Title and place of employment)



At the time the claim(s) alleged in this complaint arose, was this defendant acting under color



Prisoner Civil Rights Complaints (Rev. 11-02) 16



of state law? ___Yes ____No. If your answer if "Yes", briefly explain: __________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



3. Defendant _________________________________ is a citizen of _________________



(Name of second defendant) (State)



whose address is _______________________________________________________________,



and who is employed as _________________________________________________________.



(Title and place of employment)



At the time the claim(s) alleged in this complaint arose, was this defendant acting under color of state law?
___Yes ____No. If your answer is "Yes", briefly explain: ________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



_____________________________________________________________________________.



NOTE: If more space is needed to furnish the above information for additional defendants, continue on a blank sheet which you should label
"APPENDIX A. PARTIES".

Be sure to include the same information for each defendant including their complete address and title.



B. JURISDICTION



1. Jurisdiction is asserted pursuant to (CHECK ONE)



____ 42 U.S.C. 1983 (applies to state prisoners)



____ Bivens v. Six Unknown Named Agents of Fed. Bureau of Narcotics, 403



U.S. 388 (1971) and 28 U.S.C. 1331 (applies to federal prisoners)



Prisoner Civil Rights Complaints (Rev. 11-02) 17



2. Jurisdiction also is invoked pursuant to 28 U.S.C. 1343(a)(3). (If you wish to assert jurisdiction under different or additional statutes, you may list them below.)



C. CAUSE OF ACTION



1. I allege that the following of my constitutional rights, privileges, or immunities have been violated :

If more space is needed to explain any allegation or to list additional supporting facts, continue on a blank
sheet which you should label "APPENDIX D. CAUSE OF ACTION".



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



2. Supporting Facts: (Include all facts you consider important, including names of persons involved, places, and dates. Describe exactly how each defendant is involved.



State the facts clearly in your own words without citing legal authority or argument.



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



Prisoner Civil Rights Complaints (Rev. 11-02) 18



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



D. PREVIOUS LAWSUITS



1. Have you begun other lawsuits in state or federal court dealing with the same facts involved in this action or otherwise relating to the conditions of your imprisonment? Yes ___ No ___.
If your answer is "Yes", describe each lawsuit. (If there is more than one lawsuit, described the additional lawsuits using this same format on a blank sheet which you should label "APPENDIX E. PREVIOUS LAWSUITS".)



a. Parties to previous lawsuit:



Prisoner Civil Rights Complaints (Rev. 11-02) 19



Plaintiff(s): ______________________________________________________



______________________________________________________



Defendant(s) ______________________________________________________



______________________________________________________



b. Name and location of court and docket (case) number: _____________________



__________________________________________________________________



c. Disposition of lawsuit. (For example, was the case dismissed? Was it appealed?



It is still pending?) _________________________________________________



__________________________________________________________________



d. Issues raised: ______________________________________________________



__________________________________________________________________



__________________________________________________________________



e. Approximate date of filing lawsuit: ____________________________________



f. Approximate date of disposition: ______________________________________



E. EXHAUSTION OF PRISON OR JAIL GRIEVANCE SYSTEM



1. I have exhausted the grievance system within the jail or prison in which I am incarcerated. ____Yes ____No.

If your answer is "Yes", briefly explain the steps taken to exhaust each claim you are bringing against each Defendant. It is advisable to attach proof of exhaustion. If your answer is "No", briefly explain why the grievance system or other administrative remedies were not exhausted.



______________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



Prisoner Civil Rights Complaints (Rev. 11-02) 20



______________________________________________________________________________



______________________________________________________________________________



F. PREVIOUSLY DISMISSED ACTIONS OR APPEALS



1. If you are proceeding under 28 U.S.C. 1915, please list each civil action or appeal you have brought in a court of the United States, while you were incarcerated or detained in any facility, that was dismissed as frivolous, malicious, or for failure to state a claim upon which relief may be granted.



Please describe each civil action or appeal. If there is more than one civil action or appeal, describe the additional civil actions or appeals using this same format on a blank sheet which you should label

"APPENDIX F. PREVIOUSLY DISMISSED ACTIONS OR APPEALS".



a. Parties to previous lawsuit:



Plaintiff(s): ______________________________________________________



______________________________________________________



Defendant(s): ______________________________________________________



______________________________________________________



b. Name and location of court and docket (case) number: _____________________



__________________________________________________________________



c. Grounds for dismissal: ( ) frivolous ( ) malicious ( ) failure to state a claim upon which relief may be granted.



d. Approximate date of filing lawsuit: ____________________________________



e. Approximate date of disposition: ______________________________________



G. IMMINENT HARM



1. Are you in imminent danger of serious physical injury? _____Yes ____No. If your answer is "Yes", please describe the facts in detail below without citing legal authority or argument.



________________________________________________________________________



Prisoner Civil Rights Complaints (Rev. 11-02) 21



________________________________________________________________________



________________________________________________________________________



________________________________________________________________________



________________________________________________________________________



H. REQUEST FOR RELIEF



I request the following relief:



________________________________________________________________________



________________________________________________________________________



________________________________________________________________________



_______________________________________________________________________



_______________________________________________________________________



________________________________________________________________________



________________________________________________________________________



________________________________________________________________________



I. Request for Appointment of Attorney



I do ____ do not _____ request that an attorney be appointed to represent me in this matter. I believe
that I am in need of an attorney for these particular reasons which make it difficult for me to pursue this

matter without an attorney: _________________________________________________________



_____________________________________________________________________________



_____________________________________________________________________________



______________________________________________________________________________



______________________________________________________________________________



Prisoner Civil Rights Complaints (Rev. 11-02) 22



____________________________________



Prisoner Original Signature



DECLARATION UNDER PENALTY OF PERJURY



The undersigned declares under penalty of perjury that he/she is the plaintiff in the above action, that he/she has read the above complaint and that the information contained in the complaint is true and

correct. 28 U.S.C. 1746; 18 U.S.C. 1621.



Executed at ___________________________________ on ___________________________



(location) (date)



____________________________________



Prisoner's Original Signature

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