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6:18-cv-00402-TMC-KFM Date Filed 02/09/18 Entry Number 1-1 Page 1 of 2

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-lJiE DEPARTMENT o, ~.9AECT:o,,; MA> ,or CENSORED THIS ITEM, TH£11EF, l'IE, THE DEPARTMENT 00es NOT ~UME RESPONS1s:L.l'Y FOR rr·s COtiTENTS.

BROAD llVEA CORRECTtONAL INSTJTUr1~ S.C. DEFAATMENT OF CORRErTI""• · · 6:18-cv-00402-TMC-KFM Date Filed 02/09/18 Entry Number 1-1 Page 2 of 2

,.

RECEIVED USOC CLERK. GREENVILLE. SC

IN THE UNITED STATES DISTRICT COURT lOfB APR -2 PM I,: 02 FOR THE DISTRICT OF SOUTH CAROLINA

(Write the full name of each plaintiff who is filing

this complaint. If the names of all the plaintiffs cannot fit in the space above, please write "see attached" in the space and attach an additional page with the full list of names.)

-against-

(Write the full name of each defendant who is

being sued If the names of all the defendants cannot fit in the space above, please write "see

attached" in the space and attach an additional

page with the full list of names. Do not include addresses here.)

NOTICE

Complaint for Violation of Civil Rights (Prisoner Complaint)

Case No. ii,: I~ -o<-! o~-T V\AC.,-\C.t=-IM

(to be filled in by the Clerk's Office)

Jury Trial: ~ • No (check one)

Federal Rules of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public access to eleetronfo court files. Under this rule, papers filed with the court should not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number. A filing may include only: the last four digits of a social security number; the year of an individual's birth; a minor's initials; and the last four digits of a financial account number.

Except as noted in this form, plaintiff need not send exhibits, affidavits, grievance or witness statements, or any other materials to the Clerk's Office with this complaint.

When submitted for filing, your complaint should be accompanied by the full filing fee or an application to proceed in forma pauper is.


' '

I. The Parties to This Complaint

A. The Plaintiff{s)

Provide the information below for each plaintiff named in the complaint. Attach additional pages if needed.

Name ?Q<'fN= t}U~\['L All other names by which you have been known:

s<./76oCf ~d ~iv'w ('.6Yvedtntq,/ '5-vt.sf-✓

m Number 1·/cltoo 7-?wvad l<t' v w 12d Current Institution Co(tyn42/c; Sr C1 ;;;ll):J-/D Address

B. The Defendant(s)

Provide the information below for each defendant named in the complaint, whether the defendant is an individual, a government agency, an organization, or a corporation. Make sure that the defendant(s) listed below are identical to those contained in the above caption. For an individual defendant, include the person's job or title (if known) and check whether you are bringing this complaint against them in their individual capacity or official capacity, or both. Attach additional pages if needed.

Defendant No. I

Name

Job or Title (if known)

Shield Number

Employer

Address

~ndividual capacity

Defendant No. 2

Name

~fficial capacity

2


,.


Shield Number

Employer

Address

Capf4in/tu11! Ma..vtq%t= SauJ-t. uiy-a/4,,4 'ZJ:ej?f of &vr lfcf# .&oad 7<1vev ~

~ Individual capacity Ql .... /Official capacity

Defendant No. 3

Name


Shield Number

Employer

Address

qy-fridividual capacity

Defendant No. 4

'VOfficial capacity

Name


Shield Number

Employer

Address

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av-fndividual capacity [D_--official capacity

II. Basis for Jurisdiction

Under 42 U.S.C. § 1983, you may sue state or local officials for the "deprivation of any rights, privileges, or immunities secured by the Constitution and [federal laws]." Under Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics, 403 U.S. 388 (I 971), you may sue federal officials for the violation of certain constitutional rights.

3


,.

A. Are you bringing suit against (check all that apply):

D _.,,,Federal officials (a Bivens claim)

g/' State or local officials (a § 1983 claim)

B. Section 1983 allows claims alleging the "deprivation of any rights, privileges, or immunities secured by the Constitution and [federal laws]." 42 U.S.C. § 1983. If you

are suing under section 1983, what federal constitutional or statutory right(s) do you claim is/are being violated by state or local officials?

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C. Plaintiffs suing under Bivens may only recover for the violation of certain constitutional rights. If you are suing under Bivens, what constitutional right(s) do you

claim is/are being violated by federal officials?

D. Section 1983 allows defendants to be found liable only when they have acted "under color of any statute, ordinance, regulation, custom, or usage, of any State or Territory

or the District of Columbia." 42 U.S.C. § 1983. If you are suing under section 1983, explain how each defendant acted under color of state or local law. If you are suing

under Bivens, explain how each defendant acted under color of federal law. Attach additional pages if needed.

III. Prisoner Status

Indicate whether you are a prisoner or other confined person as follows (check all that apply):

• Pretrial detainee

~ Civilly committed detainee

• Immigration detainee

4


..

✓ • •

Convicted and sentenced state prisoner

Convicted and sentenced federal prisoner

Other (explain) ___________ _

IV. Statement of Claim

State as briefly as possible the facts of your case. Describe how each defendant was personally involved in the alleged wrongful action, along with the dates and locations of all relevant events. You may wish to include further details such as the names of other persons involved in the events giving rise to your claims. Do not cite any cases or statutes. If more than one claim is asserted, number each claim and write a short and plain statement of each claim in a separate paragraph. Attach additional pages if needed.

A.

B.

C.

If the events giving rise to your claim arose outside an institution, describe where and when they arose.

If the events giving rise to your claim arose in an institution, describe where and when they arose.

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What date and approximate time did the events giving rise to your claim(s) occur?

D. What are the facts underlying your claim(s)? (For example: What happened to you? Who did what? Was anyone else involved? Who else saw what happened?)

5


,.

V. Injuries '·

If you sustained injuries related to the events alleged above, describe your injuries and state what medical treatment, if any, you required and did or did not receive.

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VI. Relief

State briefly what you want the court to do for you. Make no legal arguments. Do not cite any cases or statutes. If requesting money damages, include the amounts of any actual damages and/or punitive damages claimed for the acts alleged. Explain the basis for these claims.

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VII. Exhaustion of Administrative Remedies Administrative Procedures

The Prison Litigation Reform Act ("PLRA"), 42 U.S.C. § 1997e(a), requires that "[n]o action shall be brought with respect to prison conditions under section 1983 of this title, 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."

Administrative remedies are also known as grievance procedures. Your case may be dismissed if you have not exhausted your administrative remedies.

6


,.

A. Did your claim(s) arise while you were confined in a jail, prison, or other correctional facility?

~Yes

• No

If yes, name the jail, prison, or other correctional facility where you were confined at the time of the events giving rise to your claim(s).

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B. Does the jail, prison, or other correctional facility where your claim(s) arose have a grievance procedure?

~Yes

• No

• Do not know

C. Does the grievance procedure at the jail, prison, or other correctional facility where your claim(s) arose cover some or all of your claims?

~es

• No

• Do not know

If yes, [hic~laim(s)?

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D. Did you file a grievance in the jail, prison, or other correctional facility where your claim(s) arose concerning the facts relating to this complaint?

~ >es ~No

7


If no, did you file a grievance about the events described in this complaint at any other jail, prison, or other correctional facility?

• Yes

~o

E. If you did file a grievance:

I • Where did you file the grievance?

2. What did you claim in your grievance?

3. What was the result, if any?

4. What steps, if any, did you take to appeal that decision? Is the grievance process completed? If not, explain why not. (Describe all efforts to appeal to

the highest level of the grievance process.)

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8


F. If you did not tile a grievance:

I. lf there are any reasons why you did not tile a grievance, state them here:

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2. If you did not tile a grievance but you did infonn officials of your claim, state who you infonned, when and how, and their respo-nse, if any:

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G. Please set forth any additional infonnation that is relevant to the exhaustion of your administrative remedies .

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(Note: You may attach as exhibits to this complaint any documents related to the exhaustion of your administrative remedies.)

VIII. Previous Lawsuits

The ''three strikes rule" bars a prisoner from bringing a civil action or an appeal in federal court without paying the filing fee if that prisoner has "on three 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).

To the best of your knowledge, have you had a case dismissed based on this ''three strikes rule"?

• Yes

~

9


If so, state which court dismissed your case, when this occurred, and attach a copy of the order if possible.

A. Have you filed other lawsuits in state or federal court dealing with the same facts involved in this action?

• Yes

~

B. If your answer to A is yes, describe each lawsuit by answering questions 1 through 7 below. (If there is more than one lawsuit, describe the additional lawsuits on another page, using the same format.)

I. Parties to the previous lawsuit

Plaintiff(s)

2.

3.

4.

5.

6.

Defendant(s)

Court (if federal court, name the district,· if state court, name the county and State)

Docket or index number

Name of Judge assigned to your case

Approximate date of filing lawsuit

Is the case still pending?

D Yes

D No

If no, give the approximate date of disposition. ________ _

IO


7. What was the result of the case? (For example: Was the case dismissed? Was

judgment entered in your favor? Was the case appealed?)

C. Have you filed other lawsuits in state or federal court otherwise relating to the conditions of your imprisonment?

• ys ~No

D. If your answer to C is yes, describe each lawsuit by answering questions I through 7 below. (If there is more than one lawsuit, describe the additional lawsuits on another page, using the same format.)

1. Parties to the previous lawsuit

Plaintiff(s)

2.

3.

4.

5.

6.

Defendant(s)

Court (if federal court, name the district; if state court, name the county and State)

Docket or index number

Name of Judge assigned to your case

Approximate date of filing lawsuit

Is the case still pending?

D Yes

• No

11


. .

lf no, give the approximate date of disposition. ________ _

7. What was the result of the case? (For example: Was the case dismissed? Was judgment entered in your favor? Was the case appealed?)

IX. Certification and Closing

Under Federal Rule of Civil Procedure 11, by signing below, I certify to the best of my knowledge, information, and belief that this complaint: ( l) is not being presented for an improper purpose, such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation; (2) is supported by existing law or by a nonfrivolous argument for extending,

modifying, or reversing existing law; (3) the factual contentions have evidentiary support or, if specifically so identified, will likely have evidentiary support after a reasonable opportunity for further investigation or discovery; and (4) the complaint otherwise complies with the requirements of Rule 11.

A. For Parties Without an Attorney

I agree to provide the Clerk's Office with any changes to my address where caserelated papers may be served. I understand that my failure to keep a current address on file with the Clerk's Office may result in the dismissal of my case.

Date of signing: f\,1.a.v-d-, )3, 20.Ll-

Signature of Plaintiff

Printed Name of Plaintiff

Prison Identification #_.;:,...;~....::s::~+--=,-----i=:::---:---------Prison Address

City State Zip Code

B. For Attorneys

Date of signing: ____ _. 20_.

Signature of Attorney

Printed Name of Attorney

Bar Number

Name of Law Firm

12


Address

Telephone Number

E-mail Address

13


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RECEIVED USOC CLERK. GREEHVILLE. SC

2018 APR -2 PH t.: 02

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USOC RECEIVED CLERK, GREENVILLE, SC

2018 APR -2 PH If: 02

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