Inmate Form for Civil Actions

INMATE FORM FOR CIVIL ACTION

Administrative Office of the Courts (Revised 02-15-00) Form CA-1

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.

5. Check whether a finding of guilty was made after a plea of:

6. If you were found guilty after a plea of not guilty, check whether that finding was made by:

7. Did you appeal from the judgment of conviction or the imposition of sentence?

If your answer is “Yes”, complete the following:

a. The name of each court to which you appealed:

b. The result in each such court to which you appealed:

c. The approximate date of each such result:

d. If known, citations of any written opinion or orders entered pursuant to such results:

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?

9. If your answer to number 8 is “Yes”, describe the lawsuit in the space below.

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:

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?

11. If your answer to number 10 is “Yes”, answer the following:

a. Did you present the facts relating to your complaint in the institution’s prisoner grievance procedures?

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.

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.

Attach additional paper if necessary.

STATEMENT OF CLAIM

17. Describe each and every 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.)

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 you are entitled.

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.