Fill and Sign the Inmate Form for Civil Actions Filed in the Court

Administrative Office of the Courts (Revised 02-15-00)Form C A-1 IN THE SUPE RIOR COURT OF STATE OF GEORGIA , Plaintiff , Civil Action No. Inmate Number vs.Nature of Action: , , , Defendant(s) INMATE FORM FOR CIVIL ACTION PART I : BACKGROUND 1. Name and location of prison in which you are now confined : 2. Sentence you are now serving : Name and location of court which imposed sentence : Approximate date your sentence will be completed : 3. The indictment number or numbers (if known) upon which, and the offense or offenses for which sentence was imposed : a. b.c. 4. Give the approximate date upon which sentence was imposed and the terms of the sentence: a.b. c. 2 Administrative Office of the Courts (Revised 02-15-00) Form C A-1 5. Check whether a finding of guilty was made after a plea of : GGuilty GGuilty but mentally ill G Nolo Contendere GNot Guilty 6. If you were fou nd gu ilt y aft er a p lea of n ot gu ilt y, ch eck w het her t hat fin din g was mad e by : GA Jury GA Judge without a Jury 7. Did you appeal from the judgment of conviction or the imposition of sentence? GYes GNo If your answer is “Yes”, comp lete the fol lowing : a. The name of each court to which you appealed : 1. 2. 3. b. The result in each such court to which you appealed : 1. 2. 3. c. The approximate date of each such result :1. 2. 3. d. If known, citations of any written opinion or orders entered pursuant to such results : 1. 2. 3. PART II: OTHER LAWSUITS 8. OTHER THAN LAWSUITS ALREADY LISTED in questions 3 through 7, have you ever begun or are you now beginning other lawsuits in federal or state courts dealing with the same facts involved in this action or relating to your imprisonment? G Yes GNo 9. If your answer to number 8 is “Yes”, describe the 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 for each lawsuit.) a.Parties to the previous lawsuit : Plaintiffs : Defendants : b. Court (If federal court, name the district. If state court, name the court and county) : c. Docket Number : 3 Administrative Office of the Courts (Revised 02-15-00) Form C A-1 d. Name of judge to whom the case was assigned : e. Date on which you filed lawsuit : f. Date of disposition, if any, of lawsuit : g. What was the lawsuit about? h.What was the outcome of the lawsuit? (For example, was the case dismissed? Was it appealed? Is it still pending?) i. Citations, if known, to any written opinions or orders in the lawsuit : PART III: GRIEVANCE PROCEDURES 10. Is there a prisoner grievance procedure at the institution in which you are presently confined? GYes GNo 11. If your answer to nu mber 10 is “ Yes”, answer the follow ing :a.Did you present the facts relating to your complaint in the institution’s prisoner grievance procedures? GYes GNo b. If your answer to (a) above is “Yes”, What steps did you take? What was the result? c. If your answer to (a) above is “No”, explain why not : 12. Tell what you have done, other than what you have described in question 11, to bring your complaints to the attention of prison officials. In so doing, give dates, places, and names of persons talked to. 4 Administrative Office of the Courts (Revised 02-15-00) Form C A-1 13. Names, approximate dates of entry and exit, and locations of all prisons and jails in which you have been incarcerated : 14. As to your present confinement, state : Which part of the penitentiary or jail you are held in : How long have you been in this part of the penitentiary or jail? The full name of every prisoner now confined in the same general area : PART IV: STATEMENT OF CLAIMS 15. List the name and address of each plaintiff in this lawsuit : 16. List below for each defendant, the defendant’s full name, official position, and place of employment. Att ach a ddi tio nal pap er i f nec ess ary. Full Name Official Position Place of Employment STATEMENT OF CLAIM 17. Des cri be ea ch an d ev ery FACT - not your opinions or views but what actually happened - supporting and explaining the basis for the lawsuit you have filed. DESCRIBE HOW EACH DEFENDANT IS INVOLVED. Include also the names of other persons involved, dates and places. If you intend to allege a number of related claims, you should number and set forth each claim separately. DO NOT GIVE ANY LEGAL ARGUMENT OR CITE ANY CASES OR STATUTES. (You may attach additional sheets of paper if necessary.) 5 Administrative Office of the Courts (Revised 02-15-00) Form C A-1 18. List the name and present address of every person you believe was a witness to the facts set forth in number 17 and BRIEFLY state what each person knows, from having seen, heard, etc., what happened. 19. Please describe any legal argument you wish to make. (You may add separate sheets of paper if necessary.) It is not necessary that you present legal argument in order to obtain the relief to which youare entitled. 6 Administrative Office of the Courts (Revised 02-15-00) Form C A-1 Sworn to and subscribed before me this _______ day of _____________________, 20_______. ______________________________________________________ Notary Public or Other Person Authorized to Administer Oaths 20. BRIEFLY state the specific relief requested against each party. This means to state exactly what you want the court to do for you. DO NOT MAKE ANY LEGAL ARGUMENTS. DO NOT CITE CASES OR STATUTES. I declare ( or certify, verify, or state) under penalty of perjury that the foregoing statements made in this Inmate Form for Civil Action are true and correct. Executed on Date Signature of Plaintiff