Fill and Sign the Martinez V Winner 548 F Supp 278casetext Form

Name Address UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO , Plaintiff CASE NO. (Full Name) (To be supplied by the Clerk) v. , Defendant(s) CIVIL RIGHTS COMPLAINT PURSUANT TO 42 U.S.C.§1983 JURISDICTION A. 1) , is a citizen of ( State ) (Plaintiff) who presently resides at (Mailing address or place of confinement) . is a citizen of Defendant 2) (Name of first defendant) , and is employed as (City, State) . At the time the claim(s) ( Position and title, if any) alleged in this complaint arose, was this defendant a cting under color of state law? No If your answer is "Yes", briefly explain: Yes 2/78 XE-2 CIVIL RIGHTS COMPLAINT (42 U.S.C. §1983) 3) (Use the back of this page to furnish the above information for additional defendants.) Jurisdiction is invoked pursuant to 28 U.S.C. §1343(3), 42 U.S.C. §1983. (If you wish to assert Jurisdiction under different or additional statutes, you may list them below.) NATURE OF THE CASE B. Briefly state the background of your case. 1) XE- 2 -2- 2/7 8 is a citizen of Defendant (Name of second defendant) , and is employed as (City, State) . At the time the claim(s) ( Position and title, if any) alleged in this complaint arose, was this defendant a cting under color of state. law No If your answer is "Yes", briefly explain: Yes 4) C. CAUSE OF ACTION 1) I allege that the following of my constitutional right s, privileges or immunities have been violated and that the following facts form the basis for my allegations: (If necessary, you may attach up to two additional pages (8 1/2" x 11") to explain any allegation or to list additional supporting facts. A)(1) Count I: (2) Supporting Facts: (Include all facts you consider import ant, 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 le agl authority or argument.) B)(1) Count II: (2) Supporting Facts: -3- XE-2 2/78 Supporting Facts: (2) PREVIOUS LAW SUITS AND ADMINISTRATIVE RELIEF D) 1) Parties to previous lawsuit. a) Plaintiffs: Defendants: Name of court and docket number: b) c) Issues raised: d) XE-2 — 4 — 2/78 C)(1) Count III: Have you begun other lawsuits in state or federal court d ealing 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, describe the additional lawsuits on another piece of paper, using the same outline.) Disposition (for example: W as the case dismissed? W as it appealed? Is it still pending? e)Approximate date of filing lawsuit: f)Approximate date of disposition: 2) E.REQUEST FOR RELIEF I believe that I am entitled to the following relief : 1) Signature of Petitioner Signature of Attorney (if any) 2/78 - 5 - XE-2 I have previously sought informal or formal releif from th e appropriate administrative officials regarding the acts complained of in Part C. Yes No If your answer is "Yes", briefly describe how relief was sought and the results. If your answer is "No," briefly explain why administrative relief was not sought. Attorney's full address and telephone number. DECLARATION UNDER PENALTY OF PERJURY on Executed at 20 . (Location) (Date) (Signature) - - 6 - XE-2 2/78 The undersigned declares under penalty of perjury that he i s the plaintiff in the above action, that he has read the above complaint and that the inf ormation contained therein is true and correct. 28 U.S.C. Sec. 1746. 18 U.S.C. Sec. 1621.