Fill and Sign the Application for Public Defender Oklahoma County Form

In the District Court of ______________________ County State of Oklahoma ____________________________ ) Plaintiff ) ) v s. ) ) Case No. ____________________ ____________________________ ) (To be entered by Court Clerk) ____________________________ ) ____________________________ ) ____________________________ ) Defendant(s) ) Petition Comes now the Plaintiff, _______________________________________, and alleges to the Court as follows: 1. The Plaintiff, (full name) _______________________________________, is an inmate confined in the penal facility located at (mailing address) _____________________________________________ ____________________________________________________________________________. 2. The Plaintiff is a resident of the State of Oklahoma and has been for ________ years. 3. (a) The Defendant, (name of first defendant) ________________________ is em ployed as (position and title, if any) _____________________________________________________. The Defendant’s employment address is (mailing address) _________________________________ _______________________________________________________________________. At the time the claim(s) alleged in this complaint arose, was this Defendant acting under Color of state law? _____ Yes, or, _____ No. If answer is ‘yes’, briefly explain: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3. (b) The Defendant, (name of second defendant) ________________________ is em ployed as (position and title, if any) _____________________________________________________. The Defendant’s employment address is (mailing address) _________________________________ _______________________________________________________________________. At the time the claim(s) alleged in this complaint arose, was this Defendant acting under color of state law? _____ Yes, or, _____ No. If your answer is ‘yes’, briefly explain: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Note: Attach additional pages to furnish the information above on each defendant. 4. Jurisdiction: ______________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. Venue: ____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. Briefly state the facts of the case: _____________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. (a) The Plaintiff alleges that the following constitutional rights, privileges or immunities have been violated: (List and designate each count separately). _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ (b) The following facts support the allegation above: (List and designate each count separately). _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 8. I have filed other lawsuits in state or federal court dealing with the same facts involved in this action. _____ Yes, or, _____ No. If the answer is ‘yes’, describe each lawsuit. (Please attach additional copies of the petition(s) and/or requests) for administrative relief). (a) Parties to the previous lawsuit: Plaintiff(s): ________________________________________________________ Defendant(s): ________________________________________________________ (b) Name of court and case number: ______________________________________ _______________________________________________________________________ (c) Case status: ____ Pending ____ Relief granted ____ Action dismissed ____ On appeal ____ Other, please specify: ______________________________________________________________________ ______________________________________________________________________ (d) Issues presented: _______________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (e) Date of filing: _______________________________________________________ (f) Date of Disposition: _________________________________________________ 9. I have sought informal or formal relief from the appropriate administration officials regarding the acts stated in allegation 8 of this Petition. _____ Yes, or, _____ No. If your answer is ‘yes’, briefly describe how relief was sought and the outcome of the proceedings. If your answer is ‘no’, briefly explain why administrative relief was not sought. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 10. Relief requested: ________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 11. Have you brought any lawsuits in state or federal court within the last ten (10) years? _____ Yes, or, _____ No. If your answer is ‘yes’, a sworn affidavit listing the litigation and the outcome of the litigation must be attached. 12. I am representing myself. _____ Yes, or, _____ No. If your answer is ‘no’, please explain. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _______________________________________ Plaintiff’s signature _______________________________________ Plaintiff’s address _______________________________________ This form is to be used by an inmate of a penal institut ion, pursuant to 12 O.S. 2004 §2003.1, for civil actions initiated against the State, the Depart ment of Corrections, another state agency or political subdivision as set forth in 57 O.S. §566. AOC Form 7 Revised 8/05