King #338791 v. NaphCare Incorporated et al

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MH
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IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Jai'Ceon Xavier King,
Plaintiff,
v.
NaphCare Inc., et al.,
Defendants.
No. CV-25-03694-PHX-JAT (MTM)
ORDER
Plaintiff Jai'Ceon Xavier King, who is confined in the Arizona State Prison
Complex-Tucson, has filed a pro se civil rights Complaint pursuant to 42 U.S.C.
§ 1983 (Doc. 1) and an Application to Proceed In Forma Pauperis (Doc. 7). The Court will
dismiss the Complaint with leave to amend.
I. Application to Proceed In Forma Pauperis and Filing Fee
The Court will grant Plaintiff’s Application to Proceed In Forma Pauperis. 28
U.S.C. § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C.
§ 1915(b)(1). The Court will assess an initial partial filing fee of $27.16. The remainder
of the fee will be collected monthly in payments of 20% of the previous month’s income
credited to Plaintiff’s trust account each time the amount in the account exceeds $10.00.
28 U.S.C. § 1915(b)(2). The Court will enter a separate Order requiring the appropriate
government agency to collect and forward the fees according to the statutory formula.
. . . .
. . . .
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II. Statutory Screening of Prisoner Complaints
The Court is required to screen complaints brought by prisoners seeking relief
against a governmental entity or an officer or an employee of a governmental entity. 28
U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff
has raised claims that are legally frivolous or malicious, fail to state a claim upon which
relief may be granted, or seek monetary relief from a defendant who is immune from such
relief. 28 U.S.C. § 1915A(b)(1)–(2).
A pleading must contain a “short and plain statement of the claim showing that the
pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 does
not demand detailed factual allegations, “it demands more than an unadorned, the-
defendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678
(2009). “Threadbare recitals of the elements of a cause of action, supported by mere
conclusory statements, do not suffice.” Id.
“[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a
claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly,
550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual content
that allows the court to draw the reasonable inference that the defendant is liable for the
misconduct alleged.” Id. “Determining whether a complaint states a plausible claim for
relief [is] . . . a context-specific task that requires the reviewing court to draw on its judicial
experience and common sense.” Id. at 679. Thus, although a plaintiff’s specific factual
allegations may be consistent with a constitutional claim, a court must assess whether there
are other “more likely explanations” for a defendant’s conduct. Id. at 681.
But as the United States Court of Appeals for the Ninth Circuit has instructed, courts
must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 342
(9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less stringent
standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. Pardus, 551
U.S. 89, 94 (2007) (per curiam)).
. . . .
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If the Court determines that a pleading could be cured by the allegation of other
facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal
of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) (en banc). The
Court will dismiss Plaintiff’s Complaint for failure to state a claim, but because it may
possibly be amended to state a claim, the Court will dismiss it with leave to amend.
III. Complaint
In his three-count Complaint, Plaintiff asserts claims based on a failure to provide
adequate medical care in violation of his Eighth Amendment rights. Plaintiff names
NaphCare Inc., Registered Nurses Barbara Barnett and Channachloe Atis, and Physician’s
Assistant Manacey Clermont as Defendants. He is seeking damages and injunctive relief.
In Count One, Plaintiff alleges that on December 23, 2024, he submitted a health
needs request (HNR) complaining of gastrointestinal issues, lower abdomen pain,
abdominal sounds, and vomiting. Plaintiff saw Defendant Barnett and told her, in
“complete detail[,] of the pain [he] was experiencing.” (Doc. 1 at 3.)1 Plaintiff said he
would like to see a gastrointestinal specialist, and Barnett responded that such requests
require authorization from the corporate office and “rarely get approved.” (Id.) Barnett
failed to make any follow-up appointments for Plaintiff and failed to follow the standards
of care for treatment. Plaintiff was later diagnosed with stage-four colon cancer, which
spread to his liver after his appointment with Barnett. Plaintiff claims that Defendant
Barnett should have sent him to the hospital or referred him to a medical provider and that
her failure to do so caused his cancer to spread to his liver.
In Count Two, Plaintiff claims that he submitted multiple HNRs concerning severe
abdominal pain, vomiting, diarrhea, and dehydration, and NaphCare staff failed to provide
effective medication, treatment, or medical advice, thereby allowing his cancer to spread.
According to Plaintiff, NaphCare nurses refused to submit a request for additional testing
after a medical report from Yuma Regional Hospital stated that a benign cyst had been
1 The citation refers to the document and page number generated by the Court’s
Case Management/Electronic Case Filing system.
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discovered on Plaintiff’s liver. Plaintiff’s request for a liver biopsy was also denied, even
though he was still experiencing “multiple severe issues.” (Id. at 4.) The cyst found on
Plaintiff’s liver was later determined to be cancerous. Plaintiff alleges that his colon cancer
spread to his liver as a result of Defendant NaphCare’s inaction.
In Count Three, Plaintiff claims that Defendant Clermont saw him in response to an
HNR he submitted in 2024 that referenced “serious abdomen pain [and] discomfort.” (Id.
at 5.) Clermont and another nurse visually assessed Plaintiff, asked about his symptoms,
and concluded he was suffering from a “buildup of gas.” (Id.) Plaintiff told Clermont that
his pain was not consistent with gas and that, based on his lack of appetite and consistent
vomiting and diarrhea, he believed he was suffering from “something more serious.” (Id.)
According to Plaintiff, Defendant Clermont offered no medication, testing, or other follow-
up procedures and failed to follow the relevant standards of care when evaluating and
diagnosing Plaintiff. As a result, Plaintiff’s cancer went undetected, allowing it to spread.
IV. Failure to State a Claim
To prevail in a § 1983 claim, a plaintiff must show that (1) acts by the defendants
(2) under color of state law (3) deprived him of federal rights, privileges or immunities and
(4) caused him damage. Thornton v. City of St. Helens, 425 F.3d 1158, 1163-64 (9th Cir.
2005) (quoting Shoshone-Bannock Tribes v. Idaho Fish & Game Comm’n, 42 F.3d 1278,
1284 (9th Cir. 1994)). In addition, a plaintiff must allege that he suffered a specific injury
as a result of the conduct of a particular defendant and he must allege an affirmative link
between the injury and the conduct of that defendant. Rizzo v. Goode, 423 U.S. 362, 371-
72, 377 (1976).
Not every claim by a prisoner relating to inadequate medical treatment states a
violation of the Eighth Amendment. To state a § 1983 medical claim, a plaintiff must show
(1) a “serious medical need” by demonstrating that failure to treat the condition could result
in further significant injury or the unnecessary and wanton infliction of pain and (2) the
defendant’s response was deliberately indifferent. Jett v. Penner, 439 F.3d 1091, 1096 (9th
Cir. 2006).
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“Deliberate indifference is a high legal standard.” Toguchi v. Chung, 391 F.3d
1051, 1060 (9th Cir. 2004). To act with deliberate indifference, a prison official must both
know of and disregard an excessive risk to inmate health; “the official must both be aware
of facts from which the inference could be drawn that a substantial risk of serious harm
exists, and he must also draw the inference.” Farmer v. Brennan, 511 U.S. 825, 837 (1994).
Deliberate indifference in the medical context may be shown by a purposeful act or failure
to respond to a prisoner’s pain or possible medical need and harm caused by the
indifference. Jett, 439 F.3d at 1096. Deliberate indifference may also be shown when a
prison official intentionally denies, delays, or interferes with medical treatment or by the
way prison doctors respond to the prisoner’s medical needs. Estelle v. Gamble, 429 U.S.
97, 104-05 (1976); Jett, 439 F.3d at 1096.
Deliberate indifference is a higher standard than negligence or lack of ordinary due
care for the prisoner’s safety. Farmer, 511 U.S. at 835. “Neither negligence nor gross
negligence will constitute deliberate indifference.” Clement v. Cal. Dep’t of Corr., 220 F.
Supp. 2d 1098, 1105 (N.D. Cal. 2002); see also Broughton v. Cutter Labs., 622 F.2d 458,
460 (9th Cir. 1980) (mere claims of “indifference,” “negligence,” or “medical malpractice”
do not support a claim under § 1983). “A difference of opinion does not amount to
deliberate indifference to [a plaintiff’s] serious medical needs.” Sanchez v. Vild, 891 F.2d
240, 242 (9th Cir. 1989). A mere delay in medical care, without more, is insufficient to
state a claim against prison officials for deliberate indifference. See Shapley v. Nev. Bd. of
State Prison Comm’rs, 766 F.2d 404, 407 (9th Cir. 1985). The indifference must be
substantial. The action must rise to a level of “unnecessary and wanton infliction of pain.”
Estelle, 429 U.S. at 105.
A. Defendant NaphCare
To state a claim under § 1983 against a private entity performing a traditional public
function, such as providing medical care to prisoners, a plaintiff must allege facts to support
that his constitutional rights were violated as a result of a policy, decision, or custom
promulgated or endorsed by the private entity. See Tsao v. Desert Palace, Inc ., 698 F.3d
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1128, 1138-39 (9th Cir. 2012); Buckner v. Toro, 116 F.3d 450, 452 (11th Cir. 1997) (per
curiam). A plaintiff must allege the specific policy or custom and how it violated his
constitutional rights. A private entity is not liable merely because it employs persons who
allegedly violated a plaintiff’s constitutional rights. See Tsao, 698 F.3d at 1139; Buckner,
116 F.3d at 452.
Plaintiff has not identified a NaphCare policy, practice, or custom that caused him
injury, and while he alludes to policies requiring corporate authorization of specialist
appointments and low rates of authorization for such requests, he fails to explain how these
policies caused him injury. Plaintiff does not allege, for example, that Defendant Barnett
would have referred him to an outside provider if corporate authorization were not required
or that she submitted a request for authorization that was denied. Accordingly, Plaintiff
has failed to state a claim against Defendant NaphCare, and this Defendant will be
dismissed, along with Count Two of the Complaint.
B. Defendants Barnett and Clermont
Plaintiff’s allegations against Defendants Barnett and Clermont are not sufficient to
state a claim against these individuals based on deliberately indifferent conduct. At most,
Plaintiff’s allegations suggest that these Defendants were negligent in failing to properly
diagnose Plaintiff or refer him for further testing. And in the absence of any allegation that
Plaintiff requested treatment for his pain, Plaintiff’s allegation that Clermont failed to
prescribe medication is not sufficient to show that this Defendant was deliberately
indifferent to Plaintiff’s pain. Accordingly, Plaintiff has failed to state an Eighth
Amendment medical claim against Defendants Barnett and Clermont, and these
Defendants will be dismissed, as will Counts One and Three.
C. Defendant Atis
Plaintiff does not allege any facts against Defendant Atis. Plaintiff has therefore
failed to state a claim against Atis, and this Defendant will be dismissed.
. . . .
. . . .
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V. Leave to Amend
For the foregoing reasons, the Court will dismiss Plaintiff’s Complaint for failure to
state a claim upon which relief may be granted. Within 30 days, Plaintiff may submit a
first amended complaint to cure the deficiencies outlined above. The Clerk of Court will
mail Plaintiff a court-approved form to use for filing a first amended complaint. If Plaintiff
fails to use the court-approved form, the Court may strike the amended complaint and
dismiss this action without further notice to Plaintiff.
Plaintiff must clearly designate on the face of the document that it is the “First
Amended Complaint.” The first amended complaint must be retyped or rewritten in its
entirety on the court-approved form and may not incorporate any part of the original
Complaint by reference. Plaintiff may include only one claim per count.
A first amended complaint supersedes the original Complaint. Ferdik v. Bonzelet,
963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner & Co., 896 F.2d
1542, 1546 (9th Cir. 1990). After amendment, the Court will treat the original Complaint
as nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised in the
original Complaint and that was voluntarily dismissed or was dismissed without prejudice
is waived if it is not alleged in a first amended complaint. Lacey v. Maricopa County, 693
F.3d 896, 928 (9th Cir. 2012) (en banc).
If Plaintiff files an amended complaint, Plaintiff must write short, plain statements
telling the Court: (1) the constitutional right Plaintiff believes was violated; (2) the name
of the Defendant who violated the right; (3) exactly what that Defendant did or failed to
do; (4) how the action or inaction of that Defendant is connected to the violation of
Plaintiff’s constitutional right; and (5) what specific injury Plaintiff suffered because of
that Defendant’s conduct. See Rizzo, 423 U.S. at 371-72, 377.
Plaintiff must repeat this process for each person he names as a Defendant. If
Plaintiff fails to affirmatively link the conduct of each named Defendant with the specific
injury suffered by Plaintiff, the allegations against that Defendant will be dismissed for
failure to state a claim. Conclusory allegations that a Defendant or group of
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Defendants has violated a constitutional right are not acceptable and will be
dismissed.
VI. Warnings
A. Release
If Plaintiff is released while this case remains pending, and the filing fee has not
been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court
that he intends to pay the unpaid balance of his filing fee within 120 days of his release or
(2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may
result in dismissal of this action.
B. Address Changes
Plaintiff must file and serve a notice of a change of address in accordance with Rule
83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion for other
relief with a notice of change of address. Failure to comply may result in dismissal of this
action.
C. Possible “Strike”
Because the Complaint has been dismissed for failure to state a claim, if Plaintiff
fails to file an amended complaint correcting the deficiencies identified in this Order, the
dismissal may count as a “strike” under the “3-strikes” provision of 28 U.S.C. § 1915(g).
Under the 3-strikes provision, a prisoner may not bring a civil action or appeal a civil
judgment in forma pauperis under 28 U.S.C. § 1915 “if the prisoner has, on 3 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).
D. Possible Dismissal
If Plaintiff fails to timely comply with every provision of this Order, including these
warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d
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at 1260-61 (a district court may dismiss an action for failure to comply with any order of
the Court).
IT IS ORDERED:
(1) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 7) is granted.
(2) As required by the accompanying Order to the appropriate government
agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing fee
of $27.16.
(3) The Complaint (Doc. 1) is dismissed for failure to state a claim. Plaintiff
has 30 days from the date this Order is filed to file a first amended complaint in compliance
with this Order.
(4) If Plaintiff fails to file an amended complaint within 30 days, the Clerk of
Court must, without further notice, enter a judgment of dismissal of this action with
prejudice that states that the dismissal may count as a “strike” under 28 U.S.C. § 1915(g)
and deny any pending unrelated motions as moot.
(5) The Clerk of Court must mail Plaintiff a court-approved form for filing a civil
rights complaint by a prisoner.
Dated this 4th day of May, 2026.
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Revised 11/6/24
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Instructions for a Prisoner Filing a Civil Rights Complaint
in the United States District Court for the District of Arizona
1. 	Who May Use This Form. 	The civil rights complaint form is designed to help incarcerated
persons prepare a complaint seeking relief for a violation of their federal civil rights. 	These
complaints typically concern, but are not limited to, conditions of confinement. 	This form
should not be used to challenge your conviction or sentence. 	If you want to challenge a state
conviction or sentence, you should file a petition under 28 U.S.C. ' 2254 for a writ of habeas
corpus by a person in state custody. 	If you want to challenge a federal conviction or sentence,
you should file a motion under 28 U.S.C. § 2255 to vacate sentence in the federal court that entered
the judgment.
2. 	The Form. 	Local Rule of Civil Procedure (LRCiv) 3.4 provides that complaints by
incarcerated persons must be filed on the court-approved form. 	The form must be typed or
neatly handwritten. The form must be completely filled in to the extent applicable. 	All questions
must be answered clearly and concisely in the appropriate space on the form. 	If needed, you may
attach additional pages, but no more than fifteen additional pages, of standard letter-sized paper.
You must identify which part of the complaint is being continued and number all pages. If you do
not fill out the form properly, you will be asked to submit additional or corrected information,
which may delay the processing of your action. 	You do not need to cite law.
3. 	Your Signature. 	You must tell the truth and sign the form. 	If you make a false statement of
a material fact, you may be prosecuted for perjury.
4. 	The Filing and Administrative Fees. 	The total fees for this action are $405.00 ($350.00 filing
fee plus $55.00 administrative fee). 	If you are unable to immediately pay the fees, you may
request leave to proceed in forma pauperis. 	Please review the “Information for Prisoners Seeking
Leave to Proceed with a (Non-Habeas) Civil Action in Federal Court In Forma Pauperis Pursuant
to 28 U.S.C. ' 1915” for additional instructions.
5. 	Original and Judge=s Copy. 	You must send an original plus one copy of your complaint and
of any other documents submitted to the Court. 	You must send one additional copy to the Court
if you wish to have a file-stamped copy of the document returned to you. 	All copies must be
identical to the original. 	Copies may be legibly handwritten. 	This section does not apply to
inmates housed at an Arizona Department of Corrections facility that participates in
electronic filing.
6. 	Where to File. 	You should file your complaint in the division where you were confined
when your rights were allegedly violated. 	See LRCiv 5.1(a) and 77.1(a). 	If you were confined
in Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. 	If you were
confined in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott Division.
If you were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file in the Tucson
Division. 	Unless you are an inmate housed at an Arizona Department of Corrections facility
that participates in electronic filing, mail the original and one copy of the complaint with the
$405 filing and administrative fees or the application to proceed in forma pauperis to:
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Phoenix & Prescott Divisions: 	OR 	Tucson Division:
U.S. District Court Clerk 	U.S. District Court Clerk
U.S. Courthouse, Suite 130 	U.S. Courthouse, Suite 1500
401 West Washington Street, SPC 10 	405 West Congress Street
Phoenix, Arizona 	85003-2119 	Tucson, Arizona 	85701-5010
7. 	Change of Address. 	You must immediately notify the Court and the defendants in writing of
any change in your mailing address. 	Failure to notify the Court of any change in your mailing
address may result in the dismissal of your case.
8. 	Certificate of Service. 	You must furnish the defendants with a copy of any document you
submit to the Court (except the initial complaint and application to proceed in forma pauperis).
Each original document (except the initial complaint and application to proceed in forma pauperis)
must include a certificate of service on the last page of the document stating the date a copy of the
document was mailed to the defendants and the address to which it was mailed. 	See Fed. R. Civ.
P. 5(a), (d). 	Any document received by the Court that does not include a certificate of service
may be stricken. 	This section does not apply to inmates housed at an Arizona Department
of Corrections facility that participates in electronic filing.
A certificate of service should be in the following form:
I hereby certify that a copy of the foregoing document was mailed
this 	(month, day, year) to:
Name:
Address:
Attorney for Defendant(s)
(Signature)
9. 	Amended Complaint. 	If you need to change any of the information in the initial complaint,
you must file an amended complaint. 	The amended complaint must be written on the court-
approved civil rights complaint form. 	You may file one amended complaint without leave
(permission) of Court within 21 days after serving it or within 21 days after any defendant has
filed an answer, whichever is earlier. 	See Fed. R. Civ. P. 15(a). 	Thereafter, you must file a
motion for leave to amend and lodge (submit) a proposed amended complaint. 	LRCiv 15.1. 	In
addition, an amended complaint may not incorporate by reference any part of your prior complaint.
LRCiv 15.1(a)(2). 	Any allegations or defendants not included in the amended complaint are
considered dismissed. 	All amended complaints are subject to screening under the Prison
Litigation Reform Act; screening your amendment will take additional processing time.
10. 	Exhibits. 	You should not submit exhibits with the complaint or amended complaint.
Instead, the relevant information should be paraphrased. 	You should keep the exhibits to use to
support or oppose a motion to dismiss, a motion for summary judgment, or at trial.
11. 	Letters and Motions. 	It is generally inappropriate to write a letter to any judge or the staff
of any judge. 	The only appropriate way to communicate with the Court is by filing a written
pleading or motion.
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12. 	Completing the Civil Rights Complaint Form.
HEADING:
1. 	Your Name. 	Print your name, prison or inmate number, and institutional mailing
address on the lines provided.
2. 	Defendants. 	If there are four or fewer defendants, print the name of each. 	If you
name more than four defendants, print the name of the first defendant on the first line,
write the words “and others” on the second line, and attach an additional page listing the
names of all of the defendants. 	Insert the additional page after page 1 and number it “1-
A” at the bottom.
3. 	Jury Demand. 	If you want a jury trial, you must write “JURY TRIAL DEMANDED”
in the space below “CIVIL RIGHTS COMPLAINT BY A PRISONER.” 	Failure to do so
may result in the loss of the right to a jury trial. 	A jury trial is not available if you are
seeking only injunctive relief.
Part A. 	JURISDICTION:
1. 	Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. ' 1983
for state, county, or city defendants; “Bivens v. Six Unknown Federal Narcotics Agents”
for federal defendants; or “other.” 	If you mark “other,” identify the source of that
authority.
2. 	Location. 	Identify the institution and city where the alleged violation of your rights
occurred.
3. 	Defendants. 	Print all of the requested information about each of the defendants in the
spaces provided. 	If you are naming more than four defendants, you must provide the
necessary information about each additional defendant on separate pages labeled “2-A,”
“2-B,” etc., at the bottom. 	Insert the additional page(s) immediately behind page 2.
Part B. 	PREVIOUS LAWSUITS:
You must identify any other lawsuit you have filed in either state or federal court while
you were a prisoner. 	Print all of the requested information about each lawsuit in the spaces
provided. 	If you have filed more than three lawsuits, you must provide the necessary information
about each additional lawsuit on a separate page. 	Label the page(s) as “2-A,” “2-B,” etc., at the
bottom of the page and insert the additional page(s) immediately behind page 2.
Part C. 	CAUSE OF ACTION:
You must identify what rights each defendant violated. 	The form provides space to allege
three separate counts (one violation per count). 	If you are alleging more than three counts, you
must provide the necessary information about each additional count on a separate page. 	Number
the additional pages “5-A,” “5-B,” etc., and insert them immediately behind page 5. 	Remember
that you are limited to a total of fifteen additional pages.
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1. 	Counts. 	You must identify which civil right was violated. 	You may allege the
violation of only one civil right per count.
2. 	Issue Involved. 	Check the box that most closely identifies the issue involved in your
claim. 	You may check only one box per count. 	If you check the box marked “Other,”
you must identify the specific issue involved.
3. 	Supporting Facts. 	After you have identified which civil right was violated, you must
state the supporting facts. 	Be as specific as possible. 	You must state what each
individual defendant did to violate your rights. 	If there is more than one defendant, you
must identify which defendant did what act. 	You also should state the date(s) on which
the act(s) occurred, if possible.
4. 	Injury. 	State precisely how you were injured by the alleged violation of your rights.
5. 	Administrative Remedies. 	You must exhaust any available administrative remedies
before you file a civil rights complaint. 	See 42 U.S.C. § 1997e. 	Consequently, you
should 	disclose 	whether 	you 	have 	exhausted 	the 	inmate 	grievance 	procedures 	or
administrative appeals for each count in your complaint. 	If the grievance procedures were
not available for any of your counts, fully explain why on the lines provided.
Part D. 	REQUEST FOR RELIEF:
Print the relief you are seeking in the space provided.
SIGNATURE:
You must sign your name and print the date you signed the complaint. 	Failure to sign the
complaint will delay the processing of your action. 	Unless you are an attorney, you may not bring
an action on behalf of anyone but yourself.
FINAL NOTE
You should follow these instructions carefully. 	Failure to do so may result in your
complaint being stricken or dismissed. 	All questions must be answered concisely in the proper
space on the form. 	If you need more space, you may attach no more than fifteen additional pages.
But the form must be completely filled in to the extent applicable. 	If you attach additional pages,
be sure to identify which section of the complaint is being continued and number the pages.
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Revised 12/1/23 	1 	550/555
___________________________________________
Name and Prisoner/Booking Number
___________________________________________
Place of Confinement
___________________________________________
Mailing Address
___________________________________________
City, State, Zip Code
(Failure to notify the Court of your change of address may result in dismissal of this action.)
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
_________________________________________ ,
(Full Name of Plaintiff)
Plaintiff,
v.
(1) _______________________________________ ,
(Full Name of Defendant)
(2) _______________________________________ ,
(3) _______________________________________ ,
(4) _______________________________________ ,
Defendant(s).
G Check if there are additional Defendants and attach page 1-A listing them.
CASE NO. __________________________________
(To be supplied by the Clerk)
CIVIL RIGHTS COMPLAINT
BY A PRISONER
G Original Complaint
G First Amended Complaint
G Second Amended Complaint
A. 	JURISDICTION
1. 	This Court has jurisdiction over this action pursuant to:
G 28 U.S.C. § 1343(a); 42 U.S.C. § 1983
G 28 U.S.C. § 1331; Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971).
G Other: 	.
2. 	Institution/city where violation occurred: 	.
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2
B. 	DEFENDANTS
1. 	Name of first Defendant: 	. 	The first Defendant is employed
as: ______________________________________________ at_______________________________________.
(Position and Title) 	(Institution)
2. 	Name of second Defendant: 	. 	The second Defendant is employed as:
as: ______________________________________________ at_______________________________________.
(Position and Title) 	(Institution)
3. 	Name of third Defendant: 	. 	The third Defendant is employed
as: ______________________________________________ at_______________________________________.
(Position and Title) 	(Institution)
4. 	Name of fourth Defendant: 	. 	The fourth Defendant is employed
as: ______________________________________________ at_______________________________________.
(Position and Title) 	(Institution)
If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page.
C. 	PREVIOUS LAWSUITS
1. 	Have you filed any other lawsuits while you were a prisoner? 	G Yes 	G No
2. 	If yes, how many lawsuits have you filed? 	. 	Describe the previous lawsuits:
a. 	First prior lawsuit:
1. 	Parties: 	v.
2. 	Court and case number: 	.
3. 	Result: 	(Was the case dismissed? 	Was it appealed? 	Is it still pending?)
.
b. 	Second prior lawsuit:
1. 	Parties: 	v.
2. 	Court and case number: 	.
3. 	Result: 	(Was the case dismissed? 	Was it appealed? 	Is it still pending?)
.
c. 	Third prior lawsuit:
1. 	Parties: 	v.
2. 	Court and case number: 	.
3. 	Result: 	(Was the case dismissed? 	Was it appealed? 	Is it still pending?)
.
If you filed more than three lawsuits, answer the questions listed above for each additional lawsuit on a separate page.
Case 2:25-cv-03694-JAT--MTM Document 9 Filed 05/04/26 Page 15 of 19

3
D. 	CAUSE OF ACTION
COUNT I
1. 	State the constitutional or other federal civil right that was violated:
.
2. 	Count I. 	Identify the issue involved. 	Check only one. 	State additional issues in separate counts.
G Basic necessities 	G Mail 	G Access to the court 	G Medical care
G Disciplinary proceedings 	G Property 	G Exercise of religion 	G Retaliation
G Excessive force by an officer 	G Threat to safety 	G Other: 	.
3. 	Supporting Facts. 	State as briefly as possible the FACTS supporting Count I. 	Describe exactly what
each Defendant did or did not do that violated your rights. 	State the facts clearly in your own words without
citing legal authority or arguments.
.
4. 	Injury. 	State how you were injured by the actions or inactions of the Defendant(s).
.
5. 	Administrative Remedies:
a. 	Are there any administrative remedies (grievance procedures or administrative appeals) available at
your institution? 	G Yes 	G No
b. 	Did you submit a request for administrative relief on Count I? 	G Yes 	G No
c. 	Did you appeal your request for relief on Count I to the highest level? 	G Yes 	G No
d. 	If you did not submit or appeal a request for administrative relief at any level, briefly explain why you
did not.
.
Case 2:25-cv-03694-JAT--MTM Document 9 Filed 05/04/26 Page 16 of 19

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COUNT II
1. 	State the constitutional or other federal civil right that was violated:
.
2. 	Count II. 	Identify the issue involved. 	Check only one. 	State additional issues in separate counts.
G Basic necessities 	G Mail 	G Access to the court 	G Medical care
G Disciplinary proceedings 	G Property 	G Exercise of religion 	G Retaliation
G Excessive force by an officer 	G Threat to safety 	G Other: 	.
3. 	Supporting Facts. 	State as briefly as possible the FACTS supporting Count II. 	Describe exactly what
each Defendant did or did not do that violated your rights. 	State the facts clearly in your own words without
citing legal authority or arguments.
.
4. 	Injury. 	State how you were injured by the actions or inactions of the Defendant(s).
.
5. 	Administrative Remedies.
a. 	Are there any administrative remedies (grievance procedures or administrative appeals) available at
your institution? 	G Yes 	G No
b. 	Did you submit a request for administrative relief on Count II? 	G Yes 	G No
c. 	Did you appeal your request for relief on Count II to the highest level? 	G Yes 	G No
d. 	If you did not submit or appeal a request for administrative relief at any level, briefly explain why you
did not.
.
Case 2:25-cv-03694-JAT--MTM Document 9 Filed 05/04/26 Page 17 of 19

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COUNT III
1. 	State the constitutional or other federal civil right that was violated:
.
2. 	Count III. 	Identify the issue involved. 	Check only one. 	State additional issues in separate counts.
G Basic necessities 	G Mail 	G Access to the court 	G Medical care
G Disciplinary proceedings 	G Property 	G Exercise of religion 	G Retaliation
G Excessive force by an officer 	G Threat to safety 	G Other: 	.
3. 	Supporting Facts. 	State as briefly as possible the FACTS supporting Count III. 	Describe exactly what
each Defendant did or did not do that violated your rights. 	State the facts clearly in your own words without
citing legal authority or arguments.
.
4. 	Injury. 	State how you were injured by the actions or inactions of the Defendant(s).
.
5. 	Administrative Remedies.
a. 	Are there any administrative remedies (grievance procedures or administrative appeals) available at
your institution? 	G Yes 	G No
b. 	Did you submit a request for administrative relief on Count III? 	G Yes 	G No
c. 	Did you appeal your request for relief on Count III to the highest level? 	G Yes 	G No
d. 	If you did not submit or appeal a request for administrative relief at any level, briefly explain why you
did not.
.
If you assert more than three Counts, answer the questions listed above for each additional Count on a separate page.
Case 2:25-cv-03694-JAT--MTM Document 9 Filed 05/04/26 Page 18 of 19

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E. 	REQUEST FOR RELIEF
State the relief you are seeking:
.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on
DATE 	SIGNATURE OF PLAINTIFF
___________________________________________
(Name and title of paralegal, legal assistant, or
other person who helped prepare this complaint)
___________________________________________
(Signature of attorney, if any)
___________________________________________
(Attorney=s address & telephone number)
ADDITIONAL PAGES
All questions must be answered concisely in the proper space on the form. 	If you need more space, you may
attach no more than fifteen additional pages. 	But the form must be completely filled in to the extent applicable.
If you attach additional pages, be sure to identify which section of the complaint is being continued and number
all pages.
Case 2:25-cv-03694-JAT--MTM Document 9 Filed 05/04/26 Page 19 of 19