FULL NAME
COMMITTED NAME (if different)
FULL ADDRESS INCLUDING NAME OF INSTITUTION
PRISON NUMBER (if applicable)
UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER
To be supplied by the Clerk
PLAINTIFF,
v.
CIVIL RIGHTS COMPLAINT
PURSUANT TO (Check one)
G 42 U.S.C. § 1983
DEFENDANT(S).
G Bivens v. Six Unknown Agents 403 U.S. 388 (1971)
A. PREVIOUS LAWSUITS
1. Have you brought any other lawsuits in a federal court while a prisoner: G Yes G No
2. If your answer to “1.” is yes, how many?
Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on an
attached piece of paper using the same outline.)
CIVIL RIGHTS COMPLAINT
CV-66 (7/97) Page 1 of 6
a. Parties to this previous lawsuit:
Plaintiff
Defendants
b. Court
c. Docket or case number
d. Name of judge to whom case was assigned
e. Disposition (For example: Was the case dismissed? If so, what was the basis for dismissal? Was it
appealed? Is it still pending?)
f. Issues raised:
g. Approximate date of filing lawsuit:
h. Approximate date of disposition
B. EXHAUSTION OF ADMINISTRATIVE REMEDIES
1. Is there a grievance procedure available at the institution where the events relating to your current complaint
occurred? G Yes G No
2. Have you filed a grievance concerning the facts relating to your current complaint? G Yes G No
If your answer is no, explain why not
3. Is the grievance procedure completed? G Yes G No
If your answer is no, explain why not
4. Please attach copies of papers related to the grievance procedure.
C. JURISDICTION
This complaint alleges that the civil rights of plaintiff
(print plaintiff's name)
who presently resides at ,
(mailing address or place of confinement)
were violated by the actions of the defendant(s) named below, which actions were directed against plaintiff at
(institution/city where violation occurred)
CIVIL RIGHTS COMPLAINT
CV-66 (7/97) Page 2 of 6
on (date or dates) , , .
(Claim I) (Claim II) (Claim III)
NOTE: You need not name more than one defendant or allege more than one claim. If you are naming more than
five (5) defendants, make a copy of this page to provide the information for additional defendants.
1. Defendant resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)
The defendant is sued in his/her (Check one or both): G individual G official capacity.
Explain how this defendant was acting under color of law:
2. Defendant resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)
The defendant is sued in his/her (Check one or both): G individual G official capacity.
Explain how this defendant was acting under color of law:
3. Defendant resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)
The defendant is sued in his/her (Check one or both): G individual G official capacity.
Explain how this defendant was acting under color of law:
CIVIL RIGHTS COMPLAINT
CV-66 (7/97) Page 3 of 6
4. Defendant resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)
The defendant is sued in his/her (Check one or both): G individual G official capacity.
Explain how this defendant was acting under color of law:
5. Defendant resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)
The defendant is sued in his/her (Check one or both): G individual G official capacity.
Explain how this defendant was acting under color of law:
CIVIL RIGHTS COMPLAINT
CV-66 (7/97) Page 4 of 6
D. CLAIMS*
CLAIM I
The following civil right has been violated:
Supporting Facts: Include all facts you consider important. State the facts clearly, in your own words, and without
citing legal authority or argument. Be certain you describe, in separately numbered paragraphs, exactly what each
DEFENDANT (by name) did to violate your right.
*If there is more than one claim, describe the additional claim(s) on another attached piece of paper using the same
outline.
CIVIL RIGHTS COMPLAINT
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E. REQUEST FOR RELIEF
I believe that I am entitled to the following specific relief:
(Date) (Signature of Plaintiff)
CIVIL RIGHTS COMPLAINT
CV-66 (7/97) Page 6 of 6
