Check the bx next t the best descriptin f yur cause f actin. Chse nly ne: Prisner Civil Rights Nn-Prisner Civil Rights Persnal In jury/t rt Tax Cllectin Practices Emplyment Discriminatin Other (specify) IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MONTANA DIVISION (Y u must fill in this blank. See Instructin 6.) (Full name f Plaintiff and prisner number, if any) Cause N. ------------- (t be filled in by Clerk f Curt) VS. Plaintiffs, COMPLAINT Jury Trial Demanded Jury Trial Nt Demanded D D (Full name f each defendant. D nt use et. a1.) Defendants. INSTRUCTIONS I. Usc this frm t file a civil cmplaint with the United States District Curt fr the District f Mntana. Yu may attach additinal pages where necessary. 2. Yur cmplaint must include nly cunts/causes f actin and facts - nt legal arguments r citatins. Plaintiff's Last Name ---------------------- Cmplaint (Revised 5/09) Page I 0/7
3. Yur cmplaint must be typed r legibly handwritten. All pleadings and ther papers submitted fr filing must be n 8 1;2" x 11" paper (letter size). Each plaintiff must sign the cmplaint (see page 7). The signatures need nt be ntarized. Hwever, each signature must be an riginal and nt a cpy. Yu must pay the Clerk fr cpies f yur cmplaint r ther curt recrds, even if yu are prceeding in fnna pauperis. The cst fr cpies is $0.50 per page and prepayment is required. 4. The filing fee fr a cmplaint is $350.00. The filing fee is set by Cngress and cannt be changed by the Curt. In additin, yu will be required t pay the cst f serving the cmplaint n each f the defendants. ]fyu are unable t prepay the entire filing fee and service csts fr this actin, yu may mve t prceed in fnna pauperis. Yur cmplaint will be returned t yu withut fili11g If it is nt accmpanied by either the full filing fee r a mtin t prceed ill frma pauperis. Please nte that prisners prceeding in frma pauperis are required t pay the full filing fee in installments. 5. Cmplaints submitted by persns prceeding in fnna pauperis and cmplaints submitted by prisners suing a gvernmental entity r emplyee are reviewed by the Curt befre the defendants are required t answer. See 28 U.S.c. 1915(e)(2), 1915A(a); 42 U.S.c. 1997e(c). After the Curt cmpletes the review prcess, yu will receive an Order explaining the findings and any further actin yu mayr must take. The review prcess may take a few mnths; each case receives the judge's individual attentin. 6. Pursuant t Standing Order DWM 27, "n prisner may maintain mre than tw (2) civil actins in fnna pauperis at ne time, unless the prisner shws that he r she is under imminent danger f serius physical injury." 7. The case captin (page 1 f this fnn) must indicate the prper Divisin fr filing. A Divisin where the alleged wrng(s) ccurred is a prper Divisin. When yu have cmpleted yur cmplaint, mail the riginal f yur cmplaint and either the full filing fee r yur mtin t prceed in frma pauperis t the prper Divisin: Billings Divisin: Clerk f U.S. District Curt, 316 N. 26th, Rm 5405, Billings, MT 59101 (Big Hrn, Carbn, Carter, Custer, Dawsn, Falln, Garfield, Glden Valley, McCne, Musselshell, Park, Petrleum, Pwder River, Prairie, Richland, Rsebud, Stillwater, Sweetgrass, Treasure, Wheatland, Wibaux r Yellwstne Cunty) Butte Divisin: Clerk f U.S. District Curt, 400 N. Main St., Federal Bldg. Rm. 303, Butte, MT 59701 (Beaverhead, Deer Ldge, Gallatin, Madisn, r Silver Bw Cunty) Plaint~frs Last Name -------------------------------- Cmplaint (Revised 5/09) Page 2 f7
Great Falls Divisin: Clerk f U.S. District Curt, 215 1st Ave. Nrth, P.O. Bx 2186, Great Falls, MT 59403 (Blaine, Cascade, Chuteau, Daniels, Fergus, Glacier, Hill, Judith Basin, Liberty, Phi1Jips, Pndera, Rsevelt, Sheridan, Tetn, Tle, r Valley Cunty) Crssrads Crrectinal Center is lcated in Tle Cunty Helena Divisin: Clerk f U.S. District Curt, 901 Frnt St., Ste 2100, Helena, MT 59626 (Bradwater, Jeffersn, Lewis & Clark, Meagher, r Pwell Cunty) Mntana State Prisn is lcated in Pwell Cunty Missula Divisin: Clerk f the U.S. District Curt, 201 E. Bradway, P.O. Bx 8537, Missula, MT 59807 (Flathead, Granite, Lake, Lincln, Mineral, Missula, Ravalli, r Sanders Cunty) COMPLAINT I. PLACE OF CONFINEMENT A. Are yu incarcerated? Yes D N D (if N, g t Part II) B. If yes, where are yu currently incarcerated? C. If any f the incidents giving rise t yur cmplaint cculted in a different facility, list that facility: A. Nn-Prisners II. EXHAUSTION OF ADMINISTRATIVE REMEDIES 1. Des any cause f actin alleged in this cmplaint require yu t exhaust administrative remedies befre filing in curt? Yes D N D Dn't Knw 0 2. If yes, have yu exhausted yur administrative remedies? Yes D ND Plaint(U"s Last Name ----------------------------- Cmplaint (Revised 5/09) Page 3 f7
B. Prisners (If yu listed ther institutins in I.e abve, please answer fr each institutin). I. Is there a grievance prcedure in yur current institutin? Yes D ND 2. Did yu fully exhaust the administrative grievance prcess within the jailr prisn where the incidents at issue ccurred? Yes D N D 3. If yu did nt fully exhaust the grievance prcess, explain why: III. PARTIES TO CURRENT LAWSUIT A. Plaintiff is a citizen f -------------------- ------------------------ presently residing at (Mailing address r place f cnfinement) B. Defendant ---------------- is a citizen f ------------------- emplyed as at (Psitin and Title, if any) (Institutin/Organizatin) Defendant ----------------- is a citizen f ------------------- emplyed as at -------------------- (Psitin and Title, if any) (Institutin/Organizatin) Defendant is a citizen f ------------------ ---------------- emplyed as at -------------------- (Psitin and Title, if any) (Institutin/Organizatin) (NOTE: Ifmre space is needed t furnish the abve infnnatin, cntinue n a blank sheet labeled "APPENDIX A: PARTIES"). Plaintiff"s Last Name Cmplaint (Revised 5/09) Page 4 0/7
IV. STATEMENT OF CLAIMS A. Cunt I (State yur cause f actin, e.g., hw have yur cnstitutinal rights been vilated): Date f incident(s): 1. Supprting Facts: (Include all facts yu cnsider imprtant, including names f persns invlved, places, and dates. State the facts clearly in yur wn wrds withut citing legal arguments, cases, r statutes). 2. Defendants Invlved: (List the name f each defendant invlved in this claim and specifically describe what each defendant did r did nt d t allegedly cause yur injury). (NOTE: Fr each additinal claim, use a blank sheet labeled "APPENDIX B. STATEMENT OF CLAIMS." Yu must set frth tw paragraphs fr each cunt, ne cnsisting f Supprting Facts (fllwing the directins under IV(A)(l )), and ne cnsisting f Defendants Invlved (fllwing the directins under JV(A)(2)). Plaintiff's Last Name Cmplaillt (Revised 5/09) Page 5 I7
V. INJURY Describe the injuries yu suffered as a result f each individual defendant's actins. (D n cite legal arguments, cases, r statutes). (NOTE: If mre space is needed t fumish the abve infrmatin, cntinue n a blank sheet labeled "APPENDIX C: INmRY"). VI. REQUEST FOR RELIEF Describe the relief yu request. (D n cite legal arguments, cases, r statutes). (NOTE: If mre space is needed t fum ish the abve infrmatin, cntinue n a blank sheet labeled "APPENDIX D: REQUEST FOR RELIEF"). Plail1t~frs Last Name ------------------------------ Cmplaint (Revised 5/09) Page 6 0/7
VII. PLAINTIFF'S DECLARATION A. I understand I must keep the Curt infrmed f my CUHent mailing address and my failure t d s may result in dismissal f this Cmplaint withut ntice t me. B. I understand the Federal Rules f Civil Prcedure prhibit litigants filing civil cmplaints frm using certain infrmatin in dcuments submitted t the Curt. In rder t cmply with these rules, I understand that: scial security numbers, taxpayer identificatin numbers, and financial accunt numbers must include nly the last fur digits (e.g. xxx-xx-5271, xx-xxx5271, xxxxxxxx3567); birth dates must include the year f birth nly (e.g. xx/xx/2001); and names f persns under the age f 18 must include initials nly (e.g. L.K.). If my dcuments (including exhibits) cntain any f the abve listed infrmatin, I understand it is my respnsibility t black that infrmatin ut befre sending thse dcuments t the Curt. I understand I am respnsible fr prtecting the privacy f this infrmatin. C. I declare under penalty f perjury that I am the plaintiff in this actin, I have read this cmplaint, and the infrmatin I set frth herein is true and COHect. 28 U.S.c. 1746; 18 U.S.c. 1621. D. (Prisners Only) This Cmplaint was depsited in the prisn system fr legal mail, pstage prepaid r paid by the prisn, n ~----,20--- Executed at n 20 (Lcatin) (Date) --------------------- -------------------, --- Signature f Plaintiff (If there is mre than ne Plaintiff, each Plaintiff must sign the cmplaint using a separate declaratins page). P laintifts Last N arne Cmplaint (Revised 5/09) Page 7 0./7