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FILED

Rev. 5/2017 Prisoner Complaint

'JAN 2 2 2019

United States District Court
Eastern District of North Carolina
Western Division

CaseNo.

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(fo be filled out by Clerk's Office orily)

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Inmate Number

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(In the space above enter the fall name(s) ofthe plaintiff(s).)

COMPLAINT
-against-

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(Pro Se Prisoner)

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(Jn the space above enter the full name(s) ofthe defendant(s). lfyou cannot
fit the names of all of the defendants in the space provided, please write
"see attached" In the space above and attach an additional sheet ofpaper
with the fall list ofnames. The names listed in the above caption mu.st be
identical to those contained in Section IV. Do not include addresses here.)

NOTICE
Federal Rule of Civil Procedure 5.2 addresses the privacy ~d security concerns resulting from
public access to electronic court tiles. Under this rule, papers filed with the court should not
contairi: an individu~'s full social secwity number or full birth date; ~e full name of a person
known to be ·a minor; _or a complete financial account number. A filing may include only: the last
four digits of a-social security number; the year of an individual's birth; a minor's initials; and
the last four di its of a financial account number.

Page1of10

Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 1 of 11

.

 Rev. 5/2017 Prisoner Complaint

I.

COMPLAINT

Indicate below the federal legal basis for your claim, ifknown. This form is designedprimarilyfor
pro se prisoners challenging the constitutionality oftheir conditions ofconfinement, claims which
are often brought under 42 U.S. C § 1983 (against state, county, or municipal defendants) or in a
"Bivens" action· (against federal defendants).

~

42 U.S.C. § 1983 (state, cowity, or municipal defcmd.ants)

0

Action under Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971)
(federal defendants)

D

Action under Federal Tort Claims Act (United States is the proper defendant; must have
presented claim in writing to the appropriate Federal agency and received a notice of final
denial of the claim pursuant to 28 U.S.C. § 240l{b))

II.

PLAINTIFF INFORMATION

Name
·- Prisoner ID #

dc&v ~ov~ Vek1114~
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57 JO Xt1e#/Le ee4etl- gl/tj}
Institutional Address
~ltif)/e f#v/lle
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Place qf Detention

City

ID.

r

State

. Zip Code

PRISONER STATUS

Indicate whether you are a prisoner or other confined person as foll~s:

~

0
0

·0
D

Pretrial detainee

D State

0 Federal

Civilly committed detainee
Immigration detainee
Convicted and .sentenced state prisoner
· Convicted and sentenced federal prisoner

Page2 of 10

Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 2 of 11

 Rev. 5/2017 Prisoner Complaint

IV.

DEFENDANT(S) INFORMATION

Please list the following information for each defendant. Ifthe correct information is not provided,
it could result in the delay or prevention ofservice. Make sure that the defendant(s) listed below
are identical to those contained in the above caption. Attach additional sheets of paper as
necessary.
. Defendant 1~

Curre~t Jo Title

tJ /:J

Q

.

6e (f'v
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· Current Work Address

Mti/~rLJ
City

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Capacity in which being sued:

Defendant 2:

cJ8fo/
Zip Code

i'Individual H'bffi~ial ~th
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J

Name

JI
State

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M'/c,l?!/~rJ
Current
Job itle

C!rr

Eed'v

CUITent Work Address

/J/~FHf~rl
City

...r

Capacity in which being sued:

;J{

}8fo /

State

Zip Code

efIndividual LefOfficial ref"Both

Page3 of 10

Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 3 of 11

 Rev. 5/2017 Prisoner Complaint

Defendant(s) Continued
Defendant 3:

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Name

~r

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Current Job Title

Current Work Address

6,r//e ~e

City
Capacity.in which being

;.}(
State

!JBfJ 7
Zip Code

sued:~Individual £3'Official ~oth

Defendant 4:

Name
CUrrent Job Title ·

Current Work Address

~Ii_~

City

dt
State

Capacity in which being sued: i;zJ' Individual

J8¢J'J
Zip Code

ri Official rifBoth

Page4 of 10

Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 4 of 11

 Rev. S/2017 Prisoner Complaint

V.

STATEMENT OF CLAIM

Place(s) of occurrence:

Date(s) of occilrrence:

I

State which of your federal constitutional ot federal statutory rights have been violated:

L(Jil' fh~.,,.t~J - /JI(

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S(ate here briefly the FACTS that support your case. Describe how each defendant was personally
involved in the alleged wrong/ill actions, state whether you were physicaIIy injured as a result of
those actions, and if so, state your injury and what medical attention was provided to you.

Who
, did what to

you?

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Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 5 of 11

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 What

happened
to you?

When did it
happen to.
you?

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Where did It
happen to
vou?

Page6of 10

Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 6 of 11

 Rev. 10/2015 Prlsqner Complain

What was
your
injury?

Page 7 of 10

Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 7 of 11

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ADMINISTRATIVE PROCEDURES

WARNING: Prisoners must exhaust administrative procedures before filing an action in federal
· court about prison conditions. 42 U.S. C. § 1997e(a). Your case may be dismissed ifyou have not
exhausted your administrative remedies,
ONo

Have you .filed a grievance concerning the facts relating to this complaint?
If no, exp in w not:

Is the grievance process completed?
If no, explain why· not:

VII.

DNo

RELIEF

State briefly what you want the court to do for you. Make no legal arguments. Cite no cases or
statutes.

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Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 9 of 11

 Rev. 10/2015 Prisoner Complaint

VID. PRISONER'S LITIGATION.IDSTORY
The "three strikes rule " bars a prisoner.from bringing a cfvii action or an appeal informapauperis
in federal court if that prisoner has "on three or more occasions, while incarcerated or detained
in any facility, brought an action or appeal in a court ofthe United States that was dismissed on
the grounds that it isfrivolous, malicious, orfails lo state a claim upon which reliefmaybe granted,
unless the prisoner is under imminent danger ofserious physical injury." 28
US.C. -§191S(g).-Have you brought any other lawsuits in state or federal court while a
prisoner?

OYes

If yes, how many?

Number each different lawsuit below and include the following:
• Name of case (including defendants' names), court, and docket number
• Nature of claim made
• How did it end? (For example, if it was dismissed~ appealed, or is still pending, explain
below.)

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Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 10 of 11

 Rev. 10/2015 Prisoner Complaint

IX.

PLAINTIFF'S DECLARATION AND WARNlNG

Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my .knowledge,
information, and belief that this complaint: (I) is not being presented for an improper purpose, such
as to harass, cause unnecessary delay, or needlessly increase the cost of litigation; (2) is supported
by existing law or by a nonfrivolous argument for extending or modifying existing law; (3) the
factual contentions have evidentiary support or, if specifically so identified, will likely have
·evidentiary support·aftenneasonabl~n>pportunity for further investigation or discovery;-and (4)·
the complaint otherwise complies with the requirements of Rule 11.
I agree to provide the Clerk's Office with any changes to my address where case-related
papers may be served. I understand that my failure to keep a current address on file With
the Clerk's Office may result in the dismissal of my case.

Each Plaintiffmust sign and date the complaint and provide prison identification number and
prison address.

Dated

Plaintiff's Signature

-. .· ~--- --..:. Printed Name

··

Prison Identification #

;Jt..
Prison Address

City

·

State

Zip Code

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II
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Case 5:19-ct-03027-D Document 1 Filed 01/22/19 Page 11 of 11