UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
INSTRUCTIONS FOR PRISONERS FILING A COMPLAINT
This packet contains two copies of a complaint form and one copy of an Application to Proceed
In Forma Pauperis. To start an action you must file an original signed and dated complaint.
Your complaint must be legibly handwritten or typewritten and the facts of the complaint must
be set out clearly and concisely in chronological order. You must sign and date the complaint and
provide complete contact information (i.e. address and prisoner number). If you need additional space to
answer a question, you may use an additional back page. Do NOT write on the reverse side of the
complaint form.
You will note that you are required to provide facts in your complaint. THE COMPLAINT
SHOULD NOT CONTAIN LEGAL ARGUMENTS OR CITATIONS.
No more than one plaintiff may be named in a complaint. Each plaintiff must file a separate
complaint and pay the filing fee or submit an Application to Proceed In Forma Pauperis.
Your complaint may be brought in this court only if one or more of the named individual
defendants are located within the geographical area covered by the United States District Court for the
Northern District of Alabama, which contains the following counties: Bibb, Blount, Calhoun, Cherokee,
Clay, Cleburne, Colbert, Cullman, DeKalb, Etowah, Fayette, Franklin, Greene, Jackson, Jefferson,
Lamar, Lauderdale, Lawrence, Limestone, Madison, Marion, Marshall, Morgan, Pickens, Shelby, St.
Clair, Sumter, Talladega, Tuscaloosa, Walker, and Winston.
You must file a separate complaint for each claim that you have unless the claims are all related
to the same incident or issue.
In order for your complaint to be filed, it must be accompanied by the filing fee of $405.00. If
you are unable to pay the filing fee for this action, you may petition the court to proceed as an indigent
party. An Application to Proceed In Forma Pauperis is included in this packet.
Mail the original complaint and the filing fee of $405.00 or an Application to Proceed In Forma
Pauperis to the following address: Clerk's Office, United States District Court, Northern District of
Alabama, Room 140, Hugo L. Black U.S. Courthouse, 1729 5th Avenue North, Birmingham, AL
35203-2195 or Clerk's Office, United States District Court, Northern District of Alabama, 101 Holmes
Avenue, Huntsville, AL 35801
Pro Se 14 (Rev. 09/16) Complaint for Violation of Civil Rights (Prisoner)
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
)
_________________________________________________ )
Plaintiff )
(Write your full name. No more than one plaintiff may be named in )
a complaint.)
)
-v- ) Case No. ______________________________
) (to be filled in by the Clerk's Office)
)
)
)
)
)
_________________________________________________ )
Defendant(s) )
(Write the full name of each defendant who is being sued. If the )
names of all of the defendants cannot fit in the space above, please )
write "see attached" in the space and attach an additional page )
with the full list of names. Do not include addresses here. Your )
complaint may be brought in this court only if one or more of the )
named defendants is located within this district.)
COMPLAINT FOR VIOLATION OF CIVIL RIGHTS
(Prisoner Complaint)
NOTICE
Federal Rules of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to
electronic court files. Under this rule, papers filed with the court should not contain: an individual's full social
security number or full birth date; the 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 digits of a financial account number.
Except as noted in this form, plaintiff need not send exhibits, affidavits, grievance or witness statements, or any
other materials to the Clerk's Office with this complaint.
In order for your complaint to be filed, it must be accompanied by the filing fee of $405.00 or an Application to
Proceed In Forma Pauperis.
Mail the original complaint and the filing fee of $405.00 or an Application to Proceed In Forma Pauperis to
the Clerk of the United States District Court for the Northern District of Alabama, Room 140, Hugo L. Black
U.S. Courthouse, 1729 5th Avenue North, Birmingham, Alabama 35203-2195.
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I. The Parties to this Complaint
A. The Plaintiff
Provide the information below for the plaintiff named in the complaint.
Name _________________________________________________________
All other names by which
you have been known: _________________________________________________________
ID Number _________________________________________________________
Current Institution _________________________________________________________
Address _________________________________________________________
_________________________ ____________ ________________
City State Zip Code
B. The Defendant(s)
Provide the information below for each defendant named in the complaint, whether the defendant is an
individual, a government agency, an organization, or a corporation. Make sure that the defendant(s) listed
below are identical to those contained in the above caption. For an individual defendant, include the
person's job or title (if known) and check whether you are bringing this complaint against them in their
individual capacity or official capacity, or both. Attach additional pages if needed.
Defendant No. 1
Name _________________________________________________________
Job or Title (if known) _________________________________________________________
Shield Number _________________________________________________________
Employer _________________________________________________________
Address _________________________________________________________
_________________________ ____________ ________________
City State Zip Code
☐ Individual Capacity ☐ Official Capacity
Defendant No. 2
Name _________________________________________________________
Job or Title (if known) _________________________________________________________
Shield Number _________________________________________________________
Employer _________________________________________________________
Address _________________________________________________________
_________________________ ____________ ________________
City State Zip Code
☐ Individual Capacity ☐ Official Capacity
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Defendant No. 3
Name _________________________________________________________
Job or Title (if known) _________________________________________________________
Shield Number _________________________________________________________
Employer _________________________________________________________
Address _________________________________________________________
_________________________ ____________ ________________
City State Zip Code
☐ Individual Capacity ☐ Official Capacity
Defendant No. 4
Name _________________________________________________________
Job or Title (if known) _________________________________________________________
Shield Number _________________________________________________________
Employer _________________________________________________________
Address _________________________________________________________
_________________________ ____________ ________________
City State Zip Code
☐ Individual Capacity ☐ Official Capacity
II. Basis for Jurisdiction
Under 42 U.S.C. ' 1983, you may sue state or local officials for the "deprivation of any rights,
privileges, or immunities secured by the Constitution and [federal law]." Under Bivens v. Six Unknown
Named Agents of Federal Bureau of Narcotics, 403 U.S. 388 (1971), you may sue federal officials for
the violation of certain constitutional rights.
A. Are you bringing suit against (check all that apply):
☐ Federal officials (a Bivens claim)
☐ State or local officials (a ' 1983 claim)
B. Section 1983 allows claims alleging the "deprivation of any rights, privileges, or immunities,
secured by the Constitution and [federal laws]." 42 U.S.C. ' 1983. If you are suing under section
1983, what federal constitutional or statutory right(s) do you claim is/are being violated by state or
local officials?
________________________________________________________________________________
________________________________________________________________________________
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C. Plaintiffs suing under Bivens may only recover for violation of certain constitutional rights. If you
are suing under Bivens, what constitutional right(s) do you claim is/are being violated by federal
officials?
________________________________________________________________________________
________________________________________________________________________________
D. Section 1983 allows defendants to be found liable only when they have acted "under color of any
statute, ordinance, regulation, custom, or usage, of any State or Territory or the District of
Columbia." 42 U.S.C. ' 1983. If you are suing under section 1983, explain how each defendant
acted under color of state or local law. If you are suing under Bivens, explain how each defendant
acted under color of federal law. Attach additional pages if needed.
________________________________________________________________________________
________________________________________________________________________________
III. Prisoner Status
Indicate whether you are a prisoner or other confined person as follows (check all that apply):
☐ Pretrial Detainee
☐ Civilly committed detainee
☐ Immigration detainee
☐ Convicted and sentenced state prisoner
☐ Convicted and sentenced federal prisoner
☐ Other ______________________________________________________________________
(explain)
IV. Statement of Claim
State as briefly as possible the facts of your case. Describe how each defendant was personally involved
in the alleged wrongful action, along with the dates and locations of all relevant events. You may wish to
include further details such as the names of other persons involved in the events giving rise to your
claims. Do not cite any cases or statutes. If more than one claim is asserted, number each claim and write
a short and plain statement of each claim in a separate paragraph. Attach additional pages if needed.
A. If the events giving rise to your claim arose outside an institution, describe where and when they
arose.
________________________________________________________________________________
________________________________________________________________________________
B. If the events giving rise to your claim arose in an institution, describe where and when they arose.
________________________________________________________________________________
________________________________________________________________________________
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C. What date and approximate time did the events giving rise to your claim(s) occur?
________________________________________________________________________________
________________________________________________________________________________
D. What are the facts underlying your claim(s)? (For example: What happened to you? Who did what?
Was anyone else involved? Who else saw what happened?)
________________________________________________________________________________
________________________________________________________________________________
V. Injuries
If you sustained injuries related to the events alleged above, describe your injuries in detail.
________________________________________________________________________________
________________________________________________________________________________
VI. Relief
State briefly what you want the court to do for you. Make no legal arguments. Do not cite any cases or
statutes. If requesting money damages, include the amounts of any actual damages and/or punitive
damages claimed for the acts alleged. Explain the basis for these claims.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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VII. Exhaustion of Administrative Remedies Administrative Procedures
The Prison Litigation Reform Act ("PLRA"), 42 U.S.C. ' 1997(a), requires that "[n]o action shall be
brought with respect to prison conditions under section 1983 of this title, or any other Federal law, by a
prisoner confined in any jail, prison, or other correctional facility until such administrative remedies as
are available are exhausted."
Administrative remedies are also known as grievance procedures. Your case may be dismissed if you
have not exhausted your administrative remedies.
A. Did your claim(s) arise while you were confined in a jail, prison, or other correctional facility?
☐ Yes
☐ No
If yes, name the jail, prison, or other correctional facility where you were confined at the time of
the events giving rise to your claim(s).
________________________________________________________________________________
B. Does the jail, prison, or other correctional facility where your claim(s) arose have a grievance
procedure?
☐ Yes
☐ No
☐ Do not know
C. Does the grievance procedure at the jail, prison, or other correctional facility where your claim(s)
arose cover some or all of your claims?
☐ Yes
☐ No
☐ Do not know
If yes, which claim(s)?
________________________________________________________________________________
________________________________________________________________________________
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D. Did you file a grievance in the jail, prison, or other correctional facility where your claim(s) arose
concerning the facts relating to this complaint?
☐ Yes
☐ No
If no, did you file a grievance about the events described in this complaint at any other jail, prison,
or other correctional facility?
☐ Yes
☐ No
E. If you did file a grievance:
1. Where did you file the grievance?
____________________________________________________________________________
2. What did you claim in your grievance?
____________________________________________________________________________
3. What was the result, if any?
____________________________________________________________________________
4. What steps, if any, did you take to appeal that decision? Is the grievance process completed? If
not, explain why not. (Describe all efforts to appeal to the highest level of the grievance
process.)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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F. If you did not file a grievance:
1. If there are any reasons why you did not file a grievance, state them here:
____________________________________________________________________________
2. If you did not file a grievance but you did inform officials of your claim, state who you
informed, when and how, and their response, if any:
____________________________________________________________________________
G. Please set forth any additional information that is relevant to the exhaustion of your administrative
remedies.
________________________________________________________________________________
________________________________________________________________________________
(Note: You may attach as exhibits to this complaint any documents related to the exhaustion of your
administrative remedies.)
VIII. Previous Lawsuits
The "three strikes rule" bars a prisoner from bringing a civil action or an appeal in federal court without
paying the filing fee if that prisoner has "on three or more prior occasions, while incarcerated or detained
in any facility, brought an action or appeal in a court of the United States that was dismissed on the
grounds that it is frivolous, malicious, or fails to state a claim upon which relief may be granted, unless
the prisoner is under imminent danger of serious physical injury." 28 U.S.C. ' 1915(g).
To the best of your knowledge, have you had any cases dismissed based on grounds that it was frivolous,
malicious, or failed to state a claim upon which relief may be granted?
☐ Yes
☐ No
If yes, state which court dismissed your case(s), when this occurred, and attach a copy of the order(s) if
possible.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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A. Have you filed other lawsuits in state or federal court dealing with the same facts involved in this
action?
☐ Yes
☐ No
B. If your answer to A is yes, describe each lawsuit by answering questions 1 through 7 below. (If
there is more than one lawsuit, describe the additional lawsuits on another page, using the same
format.)
1. Parties to the previous lawsuit
Plaintiff(s) _______________________________________________________________
Defendant(s) _______________________________________________________________
2. Court (if federal court, name the district; if state court, name the county and State)
____________________________________________________________________________
3. Docket or index number
____________________________________________________________________________
4. Name of Judge assigned to your case
____________________________________________________________________________
5. Approximate date of filing lawsuit
____________________________________________________________________________
6. Is the case still pending?
☐ Yes
☐ No
If no, give the approximate date of disposition. ________________________________________
7. What was the result of the case? (For example: Was the case dismissed? Was judgment
entered in your favor? Was the case appealed?
____________________________________________________________________________
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IX. Certification and Closing
Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my knowledge,
information, and belief that this complaint: (1) 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, modifying, or reversing existing law; (3) the
factual contentions have evidentiary support or, if specifically so identified, will likely have evidentiary
support after a reasonable opportunity 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.
Printed Name of Plaintiff _____________________________________________________
Prison Identification # _____________________________________________________
Prison Address _____________________________________________________
_______________________ ___________ ______________
City State Zip Code
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ___________________
(Date)
_____________________________________________________
Signature of Plaintiff
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FOR USE BY INCARCERATED PERSONS
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
APPLICATION TO PROCEED IN FORMA PAUPERIS
Declaring that the personal and financial information I have given below is true and correct, I
apply to this Court for authority to proceed with this case without prepayment of fees, costs, or security
1. Your full name: _______________________________________________________________
Present mailing address: ________________________________________________________
________________________________________________________
2. Are you presently employed? Yes G No G
If the answer is "yes," give the name and address of your employer and the amount of your usual
monthly salary or wages.
Name and Address: __________________________________________________
_________________________________________________________________
Amount of earnings: $____________________ per (specify pay period) ________________________
If the answer is "no," give the name and address of your last employer, when you last worked,
and the amount of the monthly salary or wages you were receiving.
Name and Address: _________________________________________________________________
_________________________________________________________________
Date last worked: _____________________
Amount of earnings: $____________________ per (specify pay period) ________________________
3. Have you received within the past twelve months any money from any of the following
sources?
(a) Business, profession, or any form of self-employment? Yes G No G
(b) Interest, dividends, rents or investment income of any kind? Yes G No G
(c) Pensions, annuities, or life insurance payments? Yes G No G
(d) Gifts or inheritances? Yes G No G
(e) Any other sources? Yes G No G
If the answer to any of the above is "yes," describe each source of money and state the amount
received from each during the past twelve months.
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____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Do you own cash, or do you have any money in any checking or saving accounts, including your
prison or jail account? Yes G No G
If the answer is "yes," state the total amount. $________________________________
5. Do you own any real estate, stocks, bonds, notes, automobiles, boats, or other valuable property
(excluding ordinary household items and clothing)? Yes G No G
If the answer is "yes," describe the property and state its approximate value.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
6. List the persons who are dependent upon you for support, stating your relationship to them and
how much you contribute toward their support.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and
correct.
Dated: _______________________ __________________________________________________
SIGNATURE OF PLAINTFF
_ADDRESS________________________________________
_________________________________________________
PRISONER NUMBER_______________________________
IMPORTANT NOTICE
Your application to proceed in forma pauperis is NOT COMPLETE and WILL NOT BE
CONSIDERED by the Court unless the page entitled "INFORMATION REGARDING
PRISONER ACCOUNTS" is properly completed and certified.
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INFORMATION REGARDING PRISONER ACCOUNTS
The Prison Litigation Reform Act, Pub. L. No. 104-134, ' 804, requires a prisoner seeking to
proceed in forma pauperis to submit information regarding his prison or jail trust account for the six
months preceding the filing of the complaint. This information must be obtained from the appropriate
official of each prison or institution at which the prisoner is or was confined within the past six months.
This information must be certified by prison or jail personnel and must include both the total deposits
made to the prisoner's account each and every month for the preceding six months and the average
monthly balance in the account each and every month during the preceding six months. Information for
six full months must be provided.
CERTIFICATION
I hereby certify that prisoner ______________________________________ has been
incarcerated in this institution since ____________________, __________, and that the prisoner has the
sum of $ __________________ in his/her prison or jail trust account on this the _______ day of
______________, __________. I further certify that the information provided below is true and correct.
Month/Year Total Deposits Received Average Account Balance
Month 1 ______________ $____________________ $______________________
Month 2 ______________ $____________________ $______________________
Month 3 ______________ $____________________ $______________________
Month 4 ______________ $____________________ $______________________
Month 5 ______________ $____________________ $______________________
Month 6 ______________ $____________________ $______________________
Current month ______________ $____________________ $______________________
(if less than full month)
Dated: _______________________ _____________________________________________
Signature of Authorized Officer of Institution
_____________________________________________
Name of Institution
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