Case 3:06-cv-01291-AWT Document 1 Filed 08/18/06 Page 1 of 7
`Case 3:06—Cv-01291-AWT Document 1 Filed 08/18/06 Page 1 Of 7
`
`UNITED STATES DISTRICT COURT
`DISTRICT OF CONNECTICUT
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`CIVIL RIGHTS COMPLAINT
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`Plaintiff(s),
`(Full name(s) and prisoner number(s) if incarcerated)
`(DO not use at at.)
`
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`v.
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`Case NO.
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`(TO be supplied
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`Defendanl(s).
`——
`(Full name(s) and capacity, fl, Official capacity, individual capacity,
`or official and individual capacitites) (DO not use at at.)
`
`A. PARTIES
`
`«MMis a citizen of QM Ed fiiflkwh
`(State)
`(Plaintiff)
`presently resides at Mgééerrd (jgcccobm EdOfig g éé {EMS/r 176%7/
`(mailing address or place Of confinement)
`If plaintiffIS incarcerated. provide inmate number.
`Zé 223/2
`
`2. Defendant @253?“ Djyzm
`(name of first defendant)
`
`is a Citizen of
`
`(4: 3
`(State)
`
`whoseaddress is
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`Case 3:06—Cv-01291-AWT Document 1 Filed 08/18/06 Page 1 Of 7
`
`UNITED STATES DISTRICT COURT
`DISTRICT OF CONNECTICUT
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`CIVIL RIGHTS COMPLAINT
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`(Ea/J Gem: Glen” “T
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`Plaintiff(s),
`(Full name(s) and prisoner number(s) if incarcerated)
`(DO not use at at.)
`
`
`
`v.
`
`Case NO.
`
`.
`0'
`zvn'swm a£ mug/c agggfiryéz‘
`
`(TO be supplied
`by the court)
`
`
`
`
`
`Defendanl(s).
`——
`(Full name(s) and capacity, fl, Official capacity, individual capacity,
`or official and individual capacitites) (DO not use at at.)
`
`A. PARTIES
`
`«MMis a citizen of QM Ed fiiflkwh
`(State)
`(Plaintiff)
`presently resides at Mgééerrd (jgcccobm EdOfig g éé {EMS/r 176%7/
`(mailing address or place Of confinement)
`If plaintiffIS incarcerated. provide inmate number.
`Zé 223/2
`
`2. Defendant @253?“ Djyzm
`(name of first defendant)
`
`is a Citizen of
`
`(4: 3
`(State)
`
`whoseaddress is
`
`j” dfiQ ende/Me (QM ye Way-29' gofig ,
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`Case 3:06-cv-01291-AWT Document 1 Filed 08/18/06 Page 2 of 7
`Case 3:06—cv-01291-AWT Document 1 Filed 08/18/06 Page 2 of 7
`
`and who is employed as
`
`
`
`(title and place of employment)
`At the time the claim(s) alleged i
`this complaint arose. was this defendant acting under
`color of state law?
`Yes
`No.
`If your answer is "Yes," briefly explain:
`
`
`
`
`3. Defendant
`
`
`
`is a citizen of
`
`(name of second defendant)
`
`(State)
`
`whose address is
`
`and who is employed as
`
`
`
`(title and place of employment)
`
`At the time the claim(s) alleged in this complaint arose, was this defendant acting under
`color of state law?
`Yes
`No.
`If your answer is "Yes." briefly explain:
`
`___—_...__.—.——————-_—————*—————‘_“—"—"_——_'—
`(If more space is needed to furnish the above information for additional defendants, continue
`on a blank sheet which you should label "A. PARTIES." Be sure to include each defendant's
`complete address and title.)
`
`B. JURISDICTION
`
`1. Jurisdiction is asserted pursuant to (CHECK ONE)
`
`l/42 u.s.c. § 1983 (applies to state prisoners)
`
`Bivens v. Six Unknown Named Agents of Fed. Bureau of
`Narcotics. 403 U.S. 388 (1971) and 28 U.S.C. § 1331 (applies to
`federal prisoners)
`
`(If you wish to assert
`2. Jurisdiction also is invoked pursuant to 28 U.S.C. § 1343(a)(3).
`jurisdiction under different or additional statutes, you may list them below.)
`
`
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`Case 3:06-cv-01291-AWT Document 1 Filed 08/18/06 Page 3 of 7
`Case 3:06—cv-01291-AWT Document 1 Filed 08/18/06 Page 3 of 7
`
`C. NATURE OF THE CASE
`
`BRIEFLY state the background of your case.
`
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`D. CAUSE OF ACTION
`
`l allege that the following of my constitutional rights, privileges, or immunities have been
`violated and that the following facts form the basis of my allegations:
`(If more space is
`needed to explain any allegation or to list additional supporting facts, continue on a blank
`sheet which you should label "D. CAUSE OF ACTION")
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`Supporting Facts: (Include all facts you consider important, including names of persons
`involved. places, and dates. Describe exactly how each defendant is involved. State the facts
`clearly in your own words without citing legal authority or argument.)
`
`W“? an. dust 3m? 05? 729 WAS'L (7'87; )5: qs-gq/Mf ”fife/ah
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`AND] More:
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`Case 3:06-cv-01291-AWT Document 1 Filed 08/18/06 Page 4 of 7
`Case 3:06—cv-01291-AWT Document 1 Filed 08/18/06 Page 4 of 7
`
`Claim II: ______________________.__.__._—————
`
`—__—_—_—________________________________.__
`
`Supporting Facts:
`
`Claim lll:
`
`
`
`
`
`Supporting Facts:
`
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`Case 3:06-cv-01291-AWT Document 1 Filed 08/18/06 Page 5 of 7
`Case 3:06—cv-01291-AWT Document 1 Filed 08/18/06 Page 5 of 7
`
`E. PREVIOUS LAWSUITS AND ADMINISTRATIVE RELIEF
`
`1. Have you begun other lawsuits in state or federal court dealing with the same facts
`involved in this action or otherwise relating to the conditions of your imprisonment?
`
`Yes
`No.
`If your answer is "Yes," describe each lawsuit.
`(If there is more than one
`lawsuit. describe the additional lawsuits using this same format on a blank sheet which you
`should label "E. PREVIOUS LAWSUITS AND ADMINISTRATIVE RELIEF.")
`
`a. Parties to previous lawsuit:
`
`Plaintiff(s):
`
`5923'/ Emit?
`
`Defendant(s):
`
`Jdgg Siam/CE ,’
`
`_
`
`b. Name and location of court and docket number (45 (end figs:- W5 fig gag get/57rd
`Bridgepré a 70%;;
`c. Disposition of lawsuit. (For example, was the case dismissed? Was it appealed?
`Is it still pending?)/
`____.__________._———-———————————--——————
`
`d. Issues raised: I /
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`e. Approximate date of filing lawsuit:
`
`(gm 5mm
`
`f. Approximate date of disposition:
`
`a «5+
`
`in;
`
`206 6
`
`I previously have sought informal or formal relief from the appropriate administrative
`2.
`
`officials regarding the acts complained of in Part D.
`V Yes
`No.
`
`If your answer is "Yes." briefly describe how relief was sought and the resuits. S‘W/waO/Kfl?
`
`3.
`
`No.
`l/Yes
`I have exhausted available administrative remedies.
`if your answer is "Yes." briefly explain the steps taken. Attach proof of exhaustion.
`If your answer is "No," briefly explain why administrative remedies were not exhausted.
`
`
`
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`Case 3:06-cv-01291-AWT Document 1 Filed 08/18/06 Page 6 of 7
`Case 3:06—cv-01291-AWT Document 1 Filed 08/18/06 Page 6 of 7
`
`F. PREVIOUSLY DISMISSED ACTIONS OR APPEALS
`
`If you are incarcerated and proceeding under 28 U.S.C. § 1915. please list each civil
`1.
`action or appeal you have brought in a court of the United States. while you were incarcerated
`or detained in any facility. that was dismissed as frivolous. malicious, or for failure to state a
`claim upon which relief may be granted. Please describe each civil action or appeal.
`If there
`is more than one civil action or appeal, describe the additional civil actions or appeals using
`this same format on a blank sheet which you should label "F. PREVIOUSLY DISMISSED
`ACTIONS OR APPEALS."
`If you are not incarcerated, go to section G.
`
`a. Parties to previous lawsuit:
`
`Plaintiff(s):
`
`Defendant(s):
`
`________—————-——————————-
`
`b. Name and location of court and docket number
`
`0. Grounds for dismissal:
`relief may be granted.
`
`( ) frivolous ( ) malicious ( ) failure to state a claim upon which
`
`d. Approximate date of filing lawsuit:
`
`e. Approximate date of disposition:
`
`
`
`No.
`Yes
`2. Are you in imminent danger of serious physical injury?
`If your answer is "Yes," please describe the facts in detail below without citing legal
`authority or argument.
`
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`Case 3:06-cv-01291-AWT Document 1 Filed 08/18/06 Page 7 of 7
`Case 3:06—cv-01291-AWT Document 1 Filed 08/18/06 Page 7 of 7
`
`I request the following relief:
`
`G. REQUEST FOR RELIEF
`
`Do you wish to have a jury trial? Yes Z
`
`No
`
`H. JURY DEMAND
`
`Original signature of attorney (if any)
`—___________
`
`Plaintiff's Original Signatur
`69 6761')? 6mm,- _
`
`Printed Name
`
`Printed Name
`
`t_)—_____—_—— Mali/may 2mm}:
`Attorney’s full address and telephone
`Plaintiff'sfull address and telephone
`
`dbr‘égem Qofgjectc w? (20 $05K
`
`Email address if available
`
`Email address if available
`
`DECLARATION UNDER PENALTY 0F PERJURY
`
`The undersigned declares under penalty of perjury that he/she is the plaintiff in the
`above action, that helshe has read the above complaint and that the information contained in
`the complaint is true and correct. 28 U.S.C. § 1746; 18 U.S.C. § 1621.
`
`Executed at [20F411:1“ otftgm'
`(location)
`
`on
`
`140639,;7': bi @525
`(date) 3
`z E:
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`
`Plaintiff‘s Original Signature
`
`(Rev. 8l25i'04)
`
`
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