Ramirez v. Lara-Uribe et al

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MDR
WO
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Jason Luis Ramirez,
Plaintiff,
v.
Enrique Lara-Uribe, et al.,
Defendants.
No. CV-26-08098-PCT-JAT (JZB)
ORDER
Self-represented Plaintiff Jason Luis Ramirez, who is confined in the Yavapai
County Detention Center, filed a civil rights Complaint pursuant to 42 U.S.C.
§ 1983 (Doc. 1) and a letter, which the Clerk of Court construed as an application to
proceed in forma pauperis. In a May 11, 2026 Order, the Court denied the letter and gave
Plaintiff 30 days to either pay the filing and administrative fees or file a complete
Application to Proceed In Forma Pauperis on a court-approved form.
On May 26, 2026, Plaintiff filed a Notice of Change of Address that is blank in the
space where Plaintiff is supposed to provide a new mailing address. He also filed another
letter (Doc. 7). He then filed an Application to Proceed In Forma Pauperis (Doc. 8). The
Court will grant the Application to Proceed, grant the letter to the extent it seeks
clarification of the May 11 Order, and 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.
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§ 1915(b)(1). The Court will not assess an initial partial filing fee. Id. The statutory filing
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.
II. Plaintiff’s May 26 Letter
In his letter, Plaintiff indicates he is unsure if he needs to file a separate lawsuit
regarding his claims against Defendant Dillashaw, noting that “the case was titled as Me
vs. (Sgt. Lara) and . . . (Dillashaw) isn’t listed in the title.”
First, as the Court explained to Plaintiff in the May 11 Order, it is improper for a
party to communicate by mailing a letter directly to the Clerk of Court, the judge, or any
court personnel. Any request for action by the Court must be in the form of a motion that
complies with the Federal Rules of Civil Procedure and the Rules of Practice of the United
States District Court for the District of Arizona (the Local Rules). Plaintiff is directed to
stop filing letters. Any future letters directed to the Clerk of Court, the judge, or any
court personnel will be stricken from the record and will be returned to Plaintiff.
Second, Plaintiff does not need to file a separate lawsuit regarding his claims against
Defendant Dillashaw. The case title and the captions of the Court’s orders refer to the first-
named Defendant and then refer generally to the other Defendants by using the Latin phrase
“et alia,” which is abbreviated as “et al.,” and means “and others.” Thus, the case title of
“Ramirez v. Lara-Uribe, et al.,” is shorthand to reflect that Plaintiff is suing Defendant
Lara-Uribe “and others,” which includes Defendant Dillashaw.
III. 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
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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 [self-represented litigant’s] filings liberally.” Hebbe v. Pliler,
627 F.3d 338, 342 (9th Cir. 2010). A “complaint [filed by a self-represented 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)).
If the Court determines a pleading could be cured by the allegation of other facts, a
self-represented 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, with leave to amend
because it may possibly be amended to state a claim.
. . . .
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IV. Complaint
In his two-count Complaint, Plaintiff names as Defendants Yavapai County
Detention Services Sergeant Enrique Lara-Uribe and Detention Officer Caleb Dillashaw.
He seeks monetary damages, policy reform, and officer training.
In Count One, Plaintiff alleges he was subjected to excessive force, in violation of
the Fourteenth Amendment. He claims that while being fingerprinted on February 28,
2026, he was “put in a wristlock and taken to the ground by multiple of[f]icers,” including
Defendant Lara-Uribe, who “struck [Plaintiff] at least three times with a closed fist in [his]
head and eye and then proceeded to strike [Plaintiff] in the ribs with his elbow . . . while
other of[f]icers were grabbing [Plaintiff].” Plaintiff asserts he suffered headaches,
dizziness, soreness in his ribs, bleeding in his eye, and mental and emotional trauma.
In Count Two, Plaintiff alleges he was subjected to a threat to his safety, in violation
of the Eighth Amendment. He claims that at 8:30 p.m. on March 30, 2026, Defendant
Dillashaw placed Plaintiff in a cell on the top tier, in full restraints “due to incidents
pertaining to Count 1.” Plaintiff asserts Defendant Dillashaw put Plaintiff in his cell and
then “walked away and out of the unit.”
Plaintiff contends he fell while trying to walk down the stairs in full restraints. He
alleges he fell, hit his head, blacked out, and “tumbled, slid and bounced down” the entire
flight of stairs. Plaintiff claims he suffered bruising, headaches, and back, leg, and foot
pain. He asserts he was lying at the bottom of the stairs, unable to move, until Defendant
Dillashaw returned. When Defendant Dillashaw tried to lift Plaintiff, he “screamed in
pain.” A nurse came and, “after what seemed like a while,” Plaintiff was transported to a
hospital.
V. Failure to State a Claim
Although self-represented pleadings are liberally construed, Haines v. Kerner, 404
U.S. 519, 520-21 (1972), conclusory and vague allegations will not support a cause of
action. Ivey v. Bd. of Regents, 673 F.2d 266, 268 (9th Cir. 1982). Further, a liberal
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interpretation of a civil rights complaint may not supply essential elements of the claim
that were not initially pled. Id.
A. Count One
The Fourteenth Amendment’s Due Process Clause applies to the use of excessive
force against pretrial detainees that amounts to punishment. Kingsley v. Hendrickson, 576
U.S. 389, 397 (2015); Gibson v. County of Washoe, 290 F.3d 1175, 1197 (9th Cir. 2002).
Force is excessive if the officers’ use of force was “objectively unreasonable” in light of
the facts and circumstances confronting them, without regard to their mental state.
Kingsley, 576 U.S. at 396; see also Graham v. Connor, 490 U.S. 386, 397 (1989) (applying
an objectively unreasonable standard to a Fourth Amendment excessive force claim arising
during an investigatory stop). In determining whether the use of force was reasonable, the
Court should consider factors including, but not limited to
the relationship between the need for the use of force and the
amount of force used; the extent of the plaintiff’s injury; any
effort made by the officer to temper or to limit the amount of
force; the severity of the security problem at issue; the threat
reasonably perceived by the officer; and whether the plaintiff
was actively resisting.
Kingsley, 576 U.S. at 397.
Because officers are often forced to make split-second decisions in rapidly evolving
situations, the reasonableness of a particular use of force must be made “from the
perspective of a reasonable officer on the scene, including what the officer knew at the
time, not with the 20/20 vision of hindsight.” Id. (citing Graham, 490 U.S. at 396).
Further, “[n]ot every push or shove, even if it may later seem unnecessary in the peace of
a judge’s chambers,” violates the Constitution. Graham, 490 U.S. at 396 (citation omitted).
Plaintiff does not explain what he was doing that resulted in officers putting him in
a wristlock, taking him to the ground, and grabbing him, and Defendant Lara-Uribe striking
him in the head and ribs. Thus, it is impossible to assess whether Defendant Lara-Uribe’s
use of force was objectively unreasonable. Absent more, Plaintiff’s allegations are too
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vague and conclusory to state an excessive force claim against Defendant Lara-Uribe.
Thus, the Court will dismiss without prejudice Count One and Defendant Lara-Uribe.
B. Count Two
A pretrial detainee has a right under the Due Process Clause of the Fourteenth
Amendment to be free from punishment prior to an adjudication of guilt. Bell v. Wolfish,
441 U.S. 520, 535 (1979). Pretrial detainees are “entitled to ‘adequate food, clothing,
shelter, sanitation, medical care, and personal safety.’” Alvarez-Machain v. United States,
107 F.3d 696, 701 (9th Cir. 1996) (quoting Hoptowit v. Ray, 682 F.2d 1237, 1246 (9th Cir.
1982)). To state a claim of unconstitutional conditions of confinement against an
individual defendant, a pretrial detainee must allege facts that show:
(i) the defendant made an intentional decision with respect to
the conditions under which the plaintiff was confined;
(ii) those conditions put the plaintiff at substantial risk of
suffering serious harm; (iii) the defendant did not take
reasonable available measures to abate that risk, even though a
reasonable official in the circumstances would have
appreciated the high degree of risk involved—making the
consequences of the defendant’s conduct obvious; and (iv) by
not taking such measures, the defendant caused the plaintiff’s
injuries.
Gordon v. County of Orange, 888 F.3d 1118, 1125 (9th Cir. 2018).
Whether the conditions and conduct rise to the level of a constitutional violation is
an objective assessment that turns on the facts and circumstances of each particular case.
Id.; Hearns v. Terhune, 413 F.3d 1036, 1042 (9th Cir. 2005). However, “a de minimis
level of imposition” is insufficient. Bell, 441 U.S. at 539 n.21. In addition, the “‘mere lack
of due care by a state official’ does not deprive an individual of life, liberty, or property
under the Fourteenth Amendment.” Castro v. County of Los Angeles, 833 F.3d 1060, 1071
(9th Cir. 2016) (quoting Daniels v. Williams, 474 U.S. 327, 330-31 (1986)). Thus, a
plaintiff must “prove more than negligence but less than subjective intent—something akin
to reckless disregard.” Id.
. . . .
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Although Plaintiff alleges Defendant Dillashaw left him fully shackled in his cell
on a top tier, Plaintiff does not explain how long Defendant Dillashaw left him in the cell
or what instructions, if any, Defendant Dillashaw gave Plaintiff regarding leaving his cell
or the tier. Nor is it clear why Plaintiff needed to leave his cell at 8:30 p.m. or whether he
sought assistance from other officers before attempting to walk down the stairs fully
shackled. Absent more, Plaintiff’s allegations are insufficient to state a claim against
Defendant Dillashaw. The Court will dismiss without prejudice Count Two and Defendant
Dillashaw.
VI. 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 raised in the original
Complaint and voluntarily dismissed or 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).
. . . .
. . . .
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VII. 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
at 1260-61 (a district court may dismiss an action for failure to comply with any order of
the Court).
. . . .
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IT IS ORDERED:
(1) Plaintiff’s letter (Doc. 7) is granted to the extent he seeks clarification of the
May 11 Order.
(2) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 8) is granted.
(3) As required by the accompanying Order to the appropriate government
agency, Plaintiff must pay the $350.00 filing fee and is not assessed an initial partial filing
fee.
(4) 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.
(5) 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.
(6) The Clerk of Court must mail Plaintiff a court-approved form for filing a civil
rights complaint by a prisoner.
Dated this 11th day of June, 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.
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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.
.
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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 3:26-cv-08098-JAT--JZB Document 9 Filed 06/12/26 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.
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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 3:26-cv-08098-JAT--JZB Document 9 Filed 06/12/26 Page 19 of 19