Martinez v. Winner, 548 F. Supp. 278

Name

Address

1) is a citizen of

who presently resides at

2) Defendant is a citizen of

, and is employed as

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:

3) Defendant is a citizen of

, and is employed as

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

Yes No

If your answer is "Yes", briefly explain:

(Use the back of this page to furnish the above information for additional defendants.)

4) Jurisdiction is invoked pursuant to 28 U.S.C. §1343(3), 42U.S.C. §1983. (If you wish to assert Jurisdiction under different or additional statutes, you may list them below.)

1) Briefly state the background of your case.

1) I allege that the following of my constitutional rights, 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 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 leagl authority or argument.)

B)(1) Count II:

(2) Supporting Facts:

C)(1) Count III:

(2) Supporting Facts:

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, describe the additional lawsuits on another piece of paper, using the same outline.)

a) Parties to previous lawsuit.

Plaintiffs:

Defendants:

b) Name of court and docket number:

c) Disposition (for example: Was the case dismissed? Was it appealed? Is it still pending?

d) Issues raised:

e) Approximate date of filing lawsuit:

f) Approximate date of disposition:

2) I have previously sought informal or formal releif from the 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.

1) I believe that I am entitled to the following relief:

Attorney's full address and telephone number.

Executed at

on

20

(Signature)