# Kolb v. Papillon

> District Court, S.D. Florida · March 22, 2021

URL: https://www.frixlaw.com/law-library/cases/10118893

## Case

- **Court:** District Court, S.D. Florida
- **Decided:** March 22, 2021
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF FLORIDA

Case No. 21-cv-21039-BLOOM

KENNETH WAYNE KOLB,

Plaintiff,

v.

FRANK PAPILLON, et al.,

Defendant.
/
ORDER
THIS CAUSE is before the Court on Plaintiff Kenneth Wayne Kolb’s Complaint pursuant
to 42 U.S.C. § 1983, (“Complaint”), ECF No. [1], and his Motion to Proceed in forma pauperis
(“Motion”), ECF No. [3]. For reasons set forth below, the Motion is denied and the Complaint is
dismissed with leave to amend.
I. MOTION TO PROCEED IN FORMA PAUPERIS
Civil complaints filed by prisoners seeking in forma pauperis status under 28 U.S.C. § 1915
are subject to the provisions of the Prison Litigation Reform Act (“PLRA”). In order to promote
the speedy, just, and efficient administration of civil rights complaints subject to the PLRA, the
court has established forms to be used by prisoners for filing civil rights actions. The court-
approved form consists of (1) a cover sheet, (2) a complaint, (3) an application to proceed in forma
pauperis, and (4) an authorization form. The authorization form, when completed by the plaintiff,
directs the agency holding the plaintiff in custody to forward to the clerk of court a certified copy
of the plaintiff’s institutional trust fund account and to disburse from the plaintiff’s account the
full statutory filing fee in amounts specified by § 1915(b). Properly completing and filing the
authorization form satisfies the plaintiff’s obligation under § 1915(a)(2) to submit a certified copy
of the plaintiff’s trust fund account with the complaint.
Plaintiff’s Motion is not on the proper form nor is it accompanied by a certified copy of his
inmate account statement for the six-month period immediately preceding the filing of the
Complaint.1 Plaintiff’s Motion to Proceed in forma pauperis is denied. Plaintiff may re-file his

Application using the court-approved form or he may pay the filing fee of $402.00 by the filing
deadline.
II. FACTUAL ALLEGATIONS
Plaintiff alleges on September 2, 2020 at approximately 1:00-2:00 A.M., while handcuffed
behind his back, Defendants C.O. Perez and Patterson were escorting Plaintiff to the shower. ECF
No. [1] at ¶ 9. In violation of written security policy, Defendants had no contact with Plaintiff and
instead followed closely behind Plaintiff. Id. Plaintiff walked down a set of stairs leading to the
showers, unassisted, and slipped in a puddle of standing water in front of the first shower. Id. at ¶
11. Plaintiff struck his head on the concrete floor and suffered injuries to his face, including a gash

over his left eye that required stitches and a broken nose. Id. at ¶¶ 11-12.
Plaintiff was escorted to medical shortly after the accident and told to stay overnight until
a doctor arrived in the morning. Id. at ¶ 13. Defendants Perez and Patterson left plaintiff handcuffed
to the infirmary bed, “all night bleeding for hours without treatment or calling a doctor that is
required to be on 24 hour call.” Id. at ¶ 32 Defendant Dr. Frank Papillon gave Plaintiff stiches over
his left eye and examined his nose but did not give him anything to treat that injury. Id. at ¶ 13.
Plaintiff was then sent back to his confinement unit. Id. X-rays of his broken nose were never
taken. Id. at ¶ 16.

1 Plaintiff provided an account statement but it was only for the period of January 1, 2021 – January 31,
2021. See ECF No. [3-1].
On September 9, 2020, with stitches in his eye, a swollen black eye, and a broken nose,
Plaintiff was transferred from Dade Correctional Institute to Tomoka Correctional Institute. Id. at
¶ 15. Following the transfer, Plaintiff filed a series of grievances regarding the incident and
subsequent medical care at Dade Correctional Institution. Id. at ¶¶ 16-27. As a result of his injury,

Plaintiff suffers from blurred vision, severe headaches, and constriction of his air passage where
his nose is broken making it difficult for him to breathe. Id. at ¶ 12.
Plaintiff alleges that Defendants Papillon, Perez, and Patterson violated his Eighth
Amendment rights and that their actions have caused “pain, suffering, physical injury, and
emotional distress.” Id. at ¶¶ 30-31. Plaintiff seeks compensatory damages in the amount of
$20,000 and $10,000 in punitive damages against each defendant. Id. at ¶¶ 2-3.
III. STANDARD OF REVIEW
The Prison Litigation Reform Act (“PLRA”), as partially codified at 18 U.S.C.
§ 1915(e)(2)(B)(i)-(iii), requires courts to screen prisoner complaints and dismiss as frivolous
claims that are “based on an indisputably meritless legal theory” or “whose factual contentions are

clearly baseless.” Denton v. Hernandez, 504 U.S. 25, 32-33 (1992); Pullen v. Sec’y, Dep’t of Corr.,
No. 19-11797-C, 2019 WL 5784952, at *1 (11th Cir. Sept. 4, 2019) (“[A]n action is frivolous if it
is without arguable merit either in law or fact.”) (quoting Napier v. Preslicka, 314 F.3d 528, 531
(11th Cir. 2002)).
Under § 1915(e)(2)(B)(ii), a complaint may be dismissed if the court determines that the
complaint fails to state a claim on which relief may be granted. Wright v. Miranda, 740 F. App’x
692, 694 (11th Cir. 2018). The standard for determining whether a complaint states a claim upon
which relief can be granted is the same whether under section 1915(e)(2)(B) or Fed. R. Civ. P.
12(b)(6). See Pullen, No. 19-11797-C, WL 5784952, at *1 (citing Mitchell v. Farcass, 112 F.3d
1483, 1490 (11th Cir. 1997)).
Pursuant to Fed. R. Civ. P. 8, a complaint must contain “a short and plain statement of the
claim showing that the pleader is entitled to relief.” See Fed. R. Civ. P. 8(a)(2). There is no required
technical form, but “each allegation must be simple, concise, and direct.” Fed. R. Civ. P. 8(d)(1).

The statement must “give the defendant fair notice of what the . . . claim is and the grounds upon
which it rests.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555 (2007) (quotation marks omitted).
Thus, “a complaint must allege sufficient facts to state a claim that is plausible on its face.”
Pullen, No. 19-11797-C, 2019 WL 5784952 at *1 (citing Ashcroft v. Iqbal, 556 U.S. 662, 678
(2009)). The “factual allegations must be enough to raise a right to relief above the speculative
level.” Bell Atl. Corp., 550 U.S. at 555 (citations omitted). Plaintiff is obligated to allege “more
than mere labels and legal conclusions, and a formulaic recitation of the elements of a cause of
action will not do.” Quality Auto Painting Ctr. of Roselle, Inc. v. State Farm Indemnity Co., 917
F.3d 1249, 1262 (11th Cir. 2019) (quoting Bell Atl. Corp., 550 U.S. at 555).
However, a district court is not required to “rewrite an otherwise deficient pleading in order

to sustain an action.” Rodriguez, 794 F. App’x at 603) (quotation marks omitted) (citation omitted)
(quoting Campbell v. Air Jamaica Ltd., 760 F.3d 1165, 1169 (11th Cir. 2014)). Moreover, a district
court “should not abandon its neutral role and begin creating arguments for a party, even an
unrepresented one.” Sims v. Hastings, 375 F. Supp. 2d 715, 718 (N.D. Ill. 2005) (citing Anderson
v. Hardman, 241 F.3d 544, 545 (7th Cir. 2001)). When read liberally, a pro se pleading “should
be interpreted ‘to raise the strongest arguments that [it] suggest[s].’” Graham v. Henderson, 89
F.3d 75, 79 (2d Cir. 1996) (quoting Burgos v. Hopkins, 14 F.3d 787, 790 (2d Cir. 1994)).
Notwithstanding the leniency afforded to pro se litigants, it does not permit them to file an
impermissible “shotgun” pleading. The Eleventh Circuit has identified four types or categories of
shotgun pleadings. See Weiland v. Palm Beach Cnty. Sheriff’s Office, 792 F.3d 1313, 1321-23
(11th Cir. 2015) (citations omitted).
The most common type of shotgun pleading is one “containing multiple counts where each
count adopts the allegations of all preceding counts, causing each successive count to carry all that

came before and the last count to be a combination of the entire complaint.” Id. The next most
common type is a complaint that is “replete with conclusory, vague, and immaterial facts not
obviously connected to any particular cause of action.” Id. The third type of shotgun pleading is
one that does not separate into a different count each cause of action or claim for relief. Id. Fourth,
and finally, there is the relatively rare shotgun pleading that asserts multiple claims against
multiple defendants without specifying which of the defendants are responsible for which acts or
omissions or which of the defendants the claim is brought against. Id.
“The unifying characteristic of all types of shotgun pleadings is that they fail to one degree
or another, and in one way or another, to give the defendants adequate notice of the claims against
them and the grounds upon which each claim rests.” Id. The Eleventh Circuit has repeatedly

condemned the use of shotgun pleadings for “imped[ing] the administration of the district courts’
civil docket.” PVC Windoors, Inc. v. Babbitbay Beach Constr., N.V., 598 F.3d 802, 806 n. 4 (11th
Cir. 2010). Indeed, shotgun pleadings require the court to sift through rambling and often
incomprehensible allegations in an attempt to separate the meritorious claims from the
unmeritorious, resulting in a “massive waste of judicial and private resources.” Id. (citation
omitted). The Eleventh Circuit, thus, has established that shotgun pleading is an unacceptable form
of establishing a claim for relief. Strategic Income Fund, LLC v. Spear, Leeds & Kellogg Corp.,
305 F.3d 1293, 1296 (11th Cir. 2002).
IV. DISCUSSION
As pled, there are several deficiencies with Plaintiff’s initial Complaint. See generally ECF
No. [1]. First, Plaintiff’s Complaint is not on the proper form. Second, because the Complaint
identifies more than one defendant, adherence to Fed. R. Civ. P. 10 should be followed more

closely. Pursuant to Fed. R. Civ. P. 10(b), “[a] party must state its claims or defenses in numbered
paragraphs, each limited as far as practicable to a single set of circumstances.” To promote clarity,
“each claim founded on a separate transaction or occurrence . . . must be stated in a separate count
or defense.” Fed. R. Civ. P. 10(b). Here, Plaintiff’s claims against multiple defendants would be
clearer if different claims were separated by count. See Weiland, 792 F.3d at 1321-23. Consistent
with the goal of Fed. R. Civ. P. 8, the amended complaint and its memorandum shall not exceed
twenty pages in length. Third, Plaintiff’s Complaint would be clearer if Plaintiff described the
allegations for his Eighth Amendment claims with more specificity. If Plaintiff intends to raise
claims that Defendants were deliberately indifferent to a serious medical need in violation of his
Eighth Amendment rights, Plaintiff should state this with clarity.

This is not an exhaustive list of the potential deficiencies in Plaintiff’s Complaint. Because
this Court is not unsympathetic, Plaintiff may have an opportunity to rectify his complaint. Plaintiff
is instructed to follow the directives and applicable rules articulated in this order if he still wishes
to pursue this action.
V. CONCLUSION
Plaintiff’s allegations fail to state a viable § 1983 claim against the named Defendants. In
order to proceed, Plaintiff shall file an amended complaint on the appropriate form providing
sufficient, factual allegations to permit the Court to review his complaint. Plaintiff is reminded that
he must state with specificity the facts supporting his claims. Plaintiff is also cautioned that each
claim should be numbered in a separate paragraph and should be set forth using short and plain
statements, with numbered paragraphs stating why the relief requested should be granted.
Furthermore, the petition must be verified – that is – signed and dated under the penalty of perjury,
pursuant to Local Rule 88.2(a)(4). Consistent with the goal of Fed. R. Civ. P. 8, the amended

complaint and its memorandum shall not exceed twenty pages in length.
Accordingly, it is ORDERED AND ADJUDGED as follows:
1. Plaintiff’s Motion to Proceed in forma pauperis ECF No. [3] is DENIED without
prejudice.
2. On or before April 19, 2021, Plaintiff shall either pay the $402.00 filing fee or may
renew his motion to proceed in forma pauperis.
3. If Plaintiff renews his motion to proceed in forma pauperis, he must have the
certificate concerning his jail account completed by an officer of the institution and
attach a certified copy of his jail account for the six-month period preceding the
filing of the Complaint in accordance with 28 U.S.C. § 1915.

4. The failure to pay the filing fee or renew his motion to proceed in forma pauperis
in accordance with the foregoing instructions will result in dismissal of this case.
5. Consistent with the purpose of Fed. R. Civ. P. 8, Plaintiff is granted leave to file an
Amended Complaint not to exceed twenty pages in length.
6. By April 19, 2021, Plaintiff shall file an Amended Complaint, signed under the
penalty of perjury, providing a short and plain statement of a claim for relief, a basis
for federal jurisdiction, and a demand for judgment. The Plaintiff shall be provided
a form complaint for use.
7. The Amended Complaint must be labeled “Amended Complaint” and must set forth
Case No. 21-cv-21039-BLOOM

Case No.: 21-CV-21039-BLOOM, so that it can be properly filed in this case.
8. The Amended Complaint must contain a separate paragraph as to each named
Defendant explaining what that Defendant did and the supporting facts to show
why that person is being sued.
9. Plaintiff is warned that failure to file the Amended Complaint on time and in
compliance with this Court’s orders will result in dismissal of this case for failure
to prosecute or failure to comply with court orders. See Fed. R. Civ. P. 41(b).
DONE AND ORDERED in Chambers at Miami, Florida, on March 22, 2021.

BETH BLOOM
UNITED STATES DISTRICT JUDGE
Forms attached
Copies to:
Counsel of Record
Kenneth Wayne Kolb, Pro Se
#069540
Tomoka Correctional Institution
3950 Tiger Bay Road
Daytona Beach, FL 32124

UNITED STATES DISTRICT COURT
for the

)
Plaintiff/Petitioner )
v. ) Civil Action No.
)
Defendant/Respondent )
APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS
(Short Form)
I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and
that I am entitled to the relief requested.
In support of this application, I answer the following questions under penalty of perjury:
1. If incarcerated. I am being held at: .
If employed there, or have an account in the institution, I have attached to this document a statement certified by the
appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any
institutional account in my name. I am also submitting a similar statement from any other institution where I was
incarcerated during the last six months.
2. If not incarcerated. If I am employed, my employer’s name and address are:
My gross pay or wages are: $ , and my take-home pay or wages are: $ per
(specify pay period) .
3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply):
(a) Business, profession, or other self-employment ’ Yes ’ No
(b) Rent payments, interest, or dividends ’ Yes ’ No
(c) Pension, annuity, or life insurance payments ’ Yes ’ No
(d) Disability, or worker’s compensation payments ’ Yes ’ No
(e) Gifts, or inheritances ’ Yes ’ No
(f) Any other sources ’ Yes ’ No
If you answered “Yes” to any question above, describe below or on separate pages each source of money and
state the amount that you received and what you expect to receive in the future.
AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)

4, Amount of money that I have in cash or in a checking or savings account: $ .
5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or
thing of value that I own, including any item of value held in someone else’s name (describe the property and its approximate
value):

6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide
the amount of the monthly expense):

7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship
with each person, and how much I contribute to their support:

8. Any debts or financial obligations (describe the amounts owed and to whom they are payable):

Declaration: I declare under penalty of perjury that the above information is true and understand that a false
statement may result in a dismissal of my claims.

Date:
Applicant’s signature

Printed name

IN THE UNITED STATES DISTRICT COURT
FOR THE __________ DISTRICT OF __________
__________ DIVISION
(Write the District and Division, if any, of the
court in which the complaint is filed.)

_________________________________________
Complaint for Violation of Civil
_________________________________________
Rights
_________________________________________
(Prisoner Complaint)
(Write the full name of each plaintiff who is filing
this complaint. If the names of all the plaintiffs Case No. _______________________
cannot fit in the space above, please write “see
(to be filled in by the Clerk’s Office)
attached” in the space and attach an additional
page with the full list of names.)
Jury Trial: ☐ Yes ☐ No
(check one)
-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

Federal Rules of Civil Procedure 5.2 addresses the privacy and security concerns resulting from public
access to electronic 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.

In order for your complaint to be filed, it must be accompanied by the filing fee or an application to
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 __________________________________________
All other names by which you have been known:
__________________________________________
__________________________________________
ID Number __________________________________________
Current Institution __________________________________________
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. 1
Name __________________________________________
Job or Title __________________________________________
(if known)
Shield Number __________________________________________
Employer __________________________________________
Address __________________________________________
__________________________________________
☐ Individual capacity ☐ Official capacity
Defendant No. 2
Name __________________________________________
Job or Title __________________________________________
(if known)
Shield Number __________________________________________
Employer __________________________________________
Address __________________________________________
__________________________________________
☐ Individual capacity ☐ Official capacity
Defendant No. 3
Name __________________________________________
Job or Title __________________________________________
(if known)
Shield Number __________________________________________
Employer __________________________________________
Address __________________________________________
__________________________________________
☐ Individual capacity ☐ Official capacity
Defendant No. 4
Name __________________________________________
Job or Title __________________________________________
(if known)
Shield Number __________________________________________
Employer __________________________________________
Address __________________________________________
__________________________________________
☐ Individual capacity ☐ 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 (1971), you may sue
federal officials for the violation of certain constitutional rights.
A. Are you bringing suit against (check all that apply):
☐ Federal officials (a Bivens claim)
☐ 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?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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
☐ 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. If the events giving rise to your claim arose outside an institution, describe where and
when they arose.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
B. If the events giving rise to your claim arose in an institution, describe where and when
they arose.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
C. 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?)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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.
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).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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?
☐ Yes
☐ No
☐ Do not know
If yes, which claim(s)?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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?
☐ Yes
☐ No
If no, did you file a grievance about the events described in this complaint at any other
jail, prison, or other correctional facility?
☐ Yes
☐ No
E. If you did file a grievance:
1. 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.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
F. If you did not file a grievance:
1. If there are any reasons why you did not file a grievance, state them here:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
2. If you did not file a grievance but you did inform officials of your claim, state
who you informed, when and how, and their response, if any:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
G. Please set forth any additional information that is relevant to the exhaustion of your
administrative remedies.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
(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
☐ No
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
☐ No
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.)
1. Parties to the previous lawsuit
Plaintiff(s) ________________________________________________
Defendant(s) ________________________________________________
2. Court (if federal court, name the district; if state court, name the county and
State)
____________________________________________________________
3. Docket or index number
____________________________________________________________
4. Name of Judge assigned to your case
____________________________________________________________
5. Approximate date of filing lawsuit
____________________________________________________________
6. Is the case still pending?
☐ Yes
☐ No
If 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?)
____________________________________________________________
____________________________________________________________
C. Have you filed other lawsuits in state or federal court otherwise relating to the
conditions of your imprisonment?
☐ Yes
☐ No
D. If your answer to C 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.)
1. Parties to the previous lawsuit
Plaintiff(s) ________________________________________________
Defendant(s) ________________________________________________
2. Court (if federal court, name the district; if state court, name the county and
State)
____________________________________________________________
____________________________________________________________
3. Docket or index number
____________________________________________________________
4. Name of Judge assigned to your case
____________________________________________________________
5. Approximate date of filing lawsuit
____________________________________________________________
6. Is the case still pending?
☐ Yes
☐ No
If 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: (1) 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 case-
related 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: __________, 20__.
Signature of Plaintiff ____________________________________________
Printed Name of Plaintiff ____________________________________________
Prison Identification # ________________________________________________
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 ___________________________________________
Address ___________________________________________
Telephone Number ___________________________________________
E-mail Address ___________________________________________

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10118893. Public record. Not legal advice.