Case: Doc 1 Filed: 04/01/19 1 of 6. PageID 1

 

 

 

 

FORM TO BE USED BY PRISONER IN
FILING A CIVIL RIGHTS COMPLAINT

   

 

 

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LN THE UNIZED STATES DISTRICT COURT
. FOR THE
NORTHERN DISTRICT OF OHIO

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. (Enter above the ??l?name of the defendant(s) in this action

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. JUDGE BURKE

 

 

 

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I. Previous Lawsuits

A. Have you begun other lawsuits in state or federal court dealing with the same facts involved in
this action or otherwise relating to your imprisonment? YES NO 

B. If your anSWer to A is yes, describe the lawsuit in the space below, (If thereis more than one
lawsuit, describe the additionallawsuits on another piece of paper, using the same outline).

1. Parties to this previous lawsuit

 

 

 

 

 

 

 

 

 

Plaintiffs 
Defendants

2. Conrt (if federal court, name the district; if state court, name the county)

 

3. Docket Number

 

4-. arue of judge to whom case was assigned?

. Case: Doc 1 Filed: 04/01/19 2 of 6. PagelD 2

El. Parties
(In item A below, place your name in the first blank and place your present address 111 the second

blank. 'Do the same for additional plaintiffs if any).
A Name of the Plaintif? QmKiliT?

Address WEKB To Tm gm dim?) LHW

(In item below place the full name of the defendant 1n the ?rst blank, his or her of?cial position

in the second blank and his or her place of employment in the third blank Use item for the
names positions and places of employment of any additional defendants).

B. DefendanLAmoeocl lain Cmyaimzq (?ashy 

 

 

 

employed as

 

 

 

 

 

 

4(1th Omhedo his at de?ated Okla ?let/{Es
Additional Defendants Ci TiuKQyt K??Mii") Mi ?3 E) WES?hot?

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IV. Statement of Claim

(State here as brie?y as possible the facts of your case Describe how each defendant 13 involved.
Include also the names of other persons involved dates and places Do not give any legal arguments
or cite any cases or statutes. If you intend to allege a number of related claims number and set

forth each claim 1n a separated paragraph. Use as much Space as you need (Attach extra sheet(s)
if necessary).

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. Case: Doc 1 Filed: 04/01/19 3 of 6. PagelD 3

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Case: Doc 1 Filed; 04/01/19 4 of 6. PagelD 4

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9 Case: Doc 1 Filed: 04/01/19 50f6. Page D#: 5

V. Relief

(State brie?y exactly what you want the court to do for you. Make no legal arguments. Cite no
cases or statutes)

Cevc?cjt' J9me 
g?thQ?b MQAKQQK EXEC) (301:) 0C)
Grade Taxw be Maw Cl

 

 

 

 

 

 

 

 

13318?ng ydayof M09595 . .. . 

I declare under penalty of perjury that the foregoing is true and correct.

gate {q Mtg?; Qi?

- (Date) (Signature gt Plaintiff)

 


revised November 199?

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DCKE 3:314 THE (399373?23
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