IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF CALIFORNIA
August 1, 2008
ROBERT HACKWORTH, PLAINTIFF,
C/O RANGEL, ET AL., DEFENDANTS.
(Name of Plaintiff) (Case Number)
Civil Rights Act, 42 U.S.C. § 1983
(Names of all Defendants)
Previous Lawsuits (list all other previous or pending lawsuits on back of this form):
A. Have you brought any other lawsuits while a prisoner? Yes No
B. If your answer to A is yes, how many?
Describe previous or pending lawsuits in the space below. (If more than one, use back of paper to continue outlining all lawsuits.)
1. Parties to previous lawsuit: Plaintiff Defendants
2. Court (if Federal Court, give name of District; if State Court, give name of County)
3. Docket Number 4. Assigned Judge
5. Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?)
6. Filing date (approx.) 7. Disposition date (approx.)
Exhaustion of Administrative Remedies
A. Is there an inmate appeal or administrative remedy process available at your institution?
B. Have you filed an appeal or grievance concerning ALL of the facts contained in this complaint?
If your answer is no, explain why not
C. Is the process completed?
Yes___ If your answer is yes, briefly explain what happened at each level.
No If your answer is no, explain why not.
Pursuant to the Prison Litigation Reform Act of 1995, "[n]o action shall be brought with respect to prison conditions under [42 U.S.C. § 1983], 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." 42 U.S.C. § 1997e(a). If there is an inmate appeal or administrative remedy process available at your institution, you may not file an action under Section 1983, or any other federal law, until you have first completed (exhausted) the process available at your institution. You are required to complete (exhaust) the inmate appeal or administrative remedy process before filing suit, regardless of the relief offered by the process. Booth v. Churner, 532 U.S. 731, 741 (2001); McKinney v. Carey, 311 F.3d 1198, 1999 (9th Cir. 2002). Even if you are seeking only money damages and the inmate appeal or administrative remedy process does not provide money, you must exhaust the process before filing suit. Booth, 532 U.S. at 734.
(In Item A below, place the full name of the defendant in the first blank, his/her official position in the second blank, and his/her place of employment in the third blank. Use item B for the names, positions and places of employment of any additional defendants.)
A. Defendant is employed as at
B. Additional defendants Statement of Claim
(State here as briefly as possible the facts of your case. Describe how each defendant is involved, including dates and places. Do not give any legal arguments or cite any cases or statutes. Attach extra sheets if necessary.)
(State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or statutes.) under penalty of perjury that the foregoing is true and correct.
Signature of Plaintiff 2/10/2006)
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