Opinion
CIVIL ACTION NO. 4:08-cv-60-DPJ-JCS.
September 16, 2008
ORDER
The Plaintiff, an inmate currently incarcerated in the East Mississippi Correctional Facility, Meridian, Mississippi, filed this complaint pursuant to 42 U.S.C. § 1983. Upon a review of the complaint submitted, the Court has determined that Plaintiff failed to submit his complaint on the appropriate forms for prisoners seeking relief pursuant to 42 U.S.C. § 1983. As such, the Plaintiff will be directed to fully complete, sign and file the attached form entitled "FORM TO BE USED BY PRISONERS IN FILING A COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983," on or before October 5, 2008. Accordingly, it is hereby,
ORDERED that on or before October 5, 2008, Plaintiff shall fully complete, sign and file the attached form entitled "FORM TO BE USED BY PRISONERS IN FILING A COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983," if he wishes to continue with this lawsuit.
Plaintiff is warned that his failure to advise this Court of a change of address or failure to comply with any Order of this Court will result in the dismissal of this case. FORM TO BE USED BY PRISONERS IN FILING A COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983 IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF MISSISSIPPI COMPLAINT (Enter above the full name of the plaintiff, prisoner, and address plaintiff in this action) (Enter above the full name of the defendant or defendants in this action)
_____________________________________ (Last Name) (Identification Number) _____________________________________ (First Name) (Middle Name) _____________________________________ (Institution) _____________________________________ (Address) V. CIVIL ACTION NUMBER: ___________________________ (to be completed by the Court) _____________________________________ _____________________________________ _____________________________________ _____________________________________ OTHER LAWSUITS FILED BY PLAINTIFF NOTICE AND WARNING: The plaintiff must fully complete the following questions. Failure to do so may result in your case being dismissed. PARTIES The plaintiff is responsible for providing his/her address and in the event of a change of address, the new address of plaintiff as well as the name(s) and address(es) of each defendant(s). Therefore, the plaintiff is required to complete the portion below: GENERAL INFORMATION not STATEMENT OF CLAIM RELIEF A. Have you ever filed any other lawsuits in a court of the United States? Yes ( ) No ( ) B. If your answer to A is yes, complete the following information for each and every civil action and appeal filed by you. (If there is more than one action, complete the following information for the additional actions on the reverse side of this page or additional sheets of paper.) 1. Parties to the action: ______________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ 2. Court (if federal court, name the district; if state court, name the county): _______________________________________________ _____________________________________________________________________________________________________________________________ 3. Docket Number: ______________________________________________________________________________________________________________ 4. Name of judge to whom case was assigned: ____________________________________________________________________________________ 5. Disposition (for example: was the case dismissed? If so, what grounds? Was it appealed? Is it still pending?): __________________________________________________________________________________________________________________ (In item I below, place your name and prisoner number in the first blank and place your present address in the second blank. Do the same for additional plaintiff, if any). I. Name of plaintiff: ___________________________ Prisoner Number: ______________________________________________________________________ Address: _______________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ (In item II below, place the full name of the defendant in the first blank, his official position in the second blank, and his place of employment in the third blank. Use the space below item II for the names, positions, and places of employment of any additional defendants.) II. Defendant: __________________________________________________________________________________________________________ is employed as _____________________________________________________________________________________________ at __________________________________ ___________________________________________________________________________________________________________________________________ PLAINTIFF: NAME: ADDRESS: ________________________________________ ________________________________________________________________________________________ ________________________________________ ________________________________________________________________________________________ DEFENDANT(S): NAME: ADDRESS: ________________________________________ ________________________________________________________________________________________ ________________________________________ ________________________________________________________________________________________ ________________________________________ ________________________________________________________________________________________ ________________________________________ ________________________________________________________________________________________ ________________________________________ ________________________________________________________________________________________ ________________________________________ ________________________________________________________________________________________ A. At the time of the incident complained of in this complaint, were you incarcerated because you had been convicted of a crime? Yes ( ) No ( ) B. Are you presently incarcerated for a parole or probation violation? Yes ( ) No ( ) C. At the time of the incident complained of in this complaint, were you an inmate of the Mississippi Department of Corrections (MDOC)? Yes ( ) No ( ) D. Are you currently an inmate of the Mississippi Department of Corrections (MDOC)? Yes ( ) No ( ) E. Have you completed the Administrative Remedy Program regarding the claims presented in this complaint? Yes ( ) No ( ), if so, state the results of the procedure: ________________________________________________________________________ _____________________________________________________________________________________________________________________________________ F. If you are an inmate of the Mississippi Department of Corrections, answer the following questions: 1. Did you present the facts relating to your complaint to the administrative or grievance procedure in your institution? Yes ( ) No ( ) 2. State how your claims were presented (written request, verbal request, request for forms): ________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 3. State the date your claims were presented: ________________________________________________________________________________ 4. State the result of the procedure: _______________________________________________________________________________________ ___________________________________________________________________________________________________________________________ III. State here as briefly as possible the facts of your case. Describe how each defendant is involved. Also, include 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 different claims, number and set forth each claim in a separate paragraph. (Use as much space as you need; attach extra sheet if necessary.) ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ IV. State what relief you seek from the court. Make no legal arguments. Cite no cases or statutes. ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ Signed this _______ day of __________________________________________________________________________, 20 __________. ____________________________________________________________ ____________________________________________________________ Signature of plaintiff, prisoner number and address of plaintiff I declare under penalty of perjury that the foregoing is true and correct. ____________________________ ____________________________________________________________ (Date) Signature of plaintiff