Case: 3:15-cv-00134-jdp Document #: 1 Filed: 03/02/15 Page 1 of 5

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United States District Court
Western District of Wisconsin

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(Full name of plamtIff( sD

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(Prisoner I.D. Number)

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Plaintiff(s),
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(Full name of defendant(sD

Defendant( s).

COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. ~ 1983
I.

PLACE OF PRESENT CONFINEMENT (Provide full address)
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NO 0

Is there a grievance procedure in your prison/jail?

B.

Have you filed a grievance conceming.the facts relating to this complaint? .
YES 8
NO 0

C.

If you have used the grievance process:
1.

Describe what you did and the result, if any.

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2.

D.

I}.

Is the grievance process completed?

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If you did not use the grievance process, explain why not.
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P\Forms\42USC 1983.Complaint
II.

YES 8L

A.

PARTIES

_

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 Case: 3:15-cv-00134-jdp Document #: 1 Filed: 03/02/15 Page 2 of 5

A.

Your name (Plaintiff)

B.

Prisoner LD. Number

D.

DEFENDANT

(name)

E.

So,k'L. ""Ke- tor (~G+I.OflCt

A,dditional DEFENDANTS

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III.

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(names and positions):

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PREVIOUS LAWSUITS
A.

Have you begun other lawsuits in state or federal court relating to the" same facts
involved in this action?
YES 0
NO ~

B.

Have you begun
.imprisonment?

C.

If your answer is YES to either of the above questions,
requested information.
1.

Defendant(s):

3.

lawsuits in state or federal
YES 0
NO 1M

court

relating

to your

provide the following

Parties to the previous lawsuit

Plaintiff(s):

2.

other

. Date filed

_

_

_

Court where case filed (if federal court, name district; if state court, name the

Complaint Under the Civil Rights Act

Page 4

 Case: 3:15-cv-00134-jdp Document #: 1 Filed: 03/02/15 Page 3 of 5

county)

-'--

_

4.

Case number and citation

-'--

_

6.

Current status (for example: Was the case dismissed? Was it appealed? Is
it still pending?)
_

7.

If resolved, date of disposition

_

8.

Ifresolved, state whetherfor'

_
(Plaintiff or Defendant)

(For additional cases, provide the above information in the same format on a separate
page.)
IV.

STATEMENT OF CLAIM
A.

State as briefly as possible the facts of your case. Describe how each named
defendant is involved. Include the names of other persons involved, dates, and
places. Describe specifically the injuries incurred. Do not give legal arguments or
cite cases or statutes. You may do that in Item "B" below. If you allege related
claims, number and set forth each claim in a separate paragraph. Use as much space
as you need to state the facts. Attach extra sheets, if necessary. Unrelated separate
claims should be raised in a separate civil action.

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Complaint Under the Civil Rights Act

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 Case: 3:15-cv-00134-jdp Document #: 1 Filed: 03/02/15 Page 4 of 5

STATEMENT OF CLAIM continued

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State briefly your legal theory or cite appropriate authority.

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Complaint Under the Civil Rights Act

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 Case: 3:15-cv-00134-jdp Document #: 1 Filed: 03/02/15 Page 5 of 5

V.

RELIEF YOU REQUEST
State briefly and exactly what you want the court to do for you. Make no legal arguments.
Do not use this space to state the facts of your claim. Use it only to request remedies for the
injuries you complain about.

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I declare under penalty of perjury that the foregoing is true and correct.
Complaint signed this ;Ll day of .Fe-btu

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Signature ofPlaintiff(s)

Prisoner J.D. Number(s)

Complaint Under the Civil Rights Act

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Page 7

 a
.'~.- #: 1-1
Case: 3:15-cv-00134-jdp Document
Filed: 03/02/15 Page 1 of 1
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