Lawtone-Bowles v. The City of New York (NYC)

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF NEW YORK

NICOLE LAWTONE-BOWLES,

Plaintiff,

-against-

THE CITY OF NEW YORK (NYC); THE CITY

OF NEW YORK DEPARTMENT OF 21-CV-5620 (LTS)

TRANSPORTATION (DOT); THE CITY OF NEW

YORK DEPARTMENT OF HEALTH (DOHMH); ORDER TO AMEND

THE CITY OF NEW YORK DEPARTMENT OF

FINANCE (DOF); THE CITY OF NEW YORK

POLICE DEPARTMENT TRAFFIC AGENTS

(TEA); THE CITY OF NEW YORK OFFICE OF

THE CORPORATION COUNSEL (LAW),

Defendants.

LAURA TAYLOR SWAIN, Chief United States District Judge:

Plaintiff, who is a resident of Highland Falls, in Orange County, New York, appears pro

se. She brings this action under the Americans with Disabilities Act, alleging that the City of

New York failed to accommodate her disability in connection with her application for a disabled

person parking permit. By order dated June 29, 2021, the Court granted Plaintiff’s request to

proceed without prepayment of fees, that is, in forma pauperis.

For the reasons set forth below, the Court grants Plaintiff leave to file an amended

complaint within sixty days of the date of this order.

STANDARD OF REVIEW

The Court must dismiss an in forma pauperis complaint, or any portion of the complaint,

that is frivolous or malicious, fails to state a claim on which relief may be granted, or seeks

monetary relief from a defendant who is immune from such relief. 28 U.S.C. § 1915(e)(2)(B);

see Livingston v. Adirondack Beverage Co., 141 F.3d 434, 437 (2d Cir. 1998). The Court must

also dismiss a complaint when the Court lacks subject matter jurisdiction. See Fed. R. Civ. P.

12(h)(3).

While the law mandates dismissal on any of these grounds, the Court is obliged to

construe pro se pleadings liberally, Harris v. Mills, 572 F.3d 66, 72 (2d Cir. 2009), and interpret

them to raise the “strongest [claims] that they suggest,” Triestman v. Fed. Bureau of Prisons, 470

F.3d 471, 474 (2d Cir. 2006) (internal quotation marks and citations omitted, emphasis in

original). But the “special solicitude” in pro se cases, id. at 475 (citation omitted), has its limits –

to state a claim, pro se pleadings still must comply with Rule 8 of the Federal Rules of Civil

Procedure, which requires a complaint to make a short and plain statement showing that the

pleader is entitled to relief.

The Supreme Court has held that, under Rule 8, a complaint must include enough facts to

state a claim for relief “that is plausible on its face.” Bell Atl. Corp. v. Twombly, 550 U.S. 544,

570 (2007). A claim is facially plausible if the plaintiff pleads enough factual detail to allow the

Court to draw the inference that the defendant is liable for the alleged misconduct. In reviewing

the complaint, the Court must accept all well-pleaded factual allegations as true. Ashcroft v.

Iqbal, 556 U.S. 662, 678-79 (2009). But it does not have to accept as true “[t]hreadbare recitals

of the elements of a cause of action,” which are essentially just legal conclusions. Id. (citing

Twombly, 550 U.S. at 555). After separating legal conclusions from well-pleaded factual

allegations, the Court must determine whether those facts make it plausible – not merely possible

– that the pleader is entitled to relief. Id.

BACKGROUND

Plaintiff Nicole Lawtone-Bowles alleges the following facts. Plaintiff has been disabled

since 2008. (ECF 2 at 5.) She is “permanently disable[d] with bilateral knee [sic] and ha[s]

recently been diagnos[ed] with [f]ibromyalgia,” which causes her “widespread musculoskeletal

pain, accompanied by fatigue, sleep, memory and mood issues.” (Id.)

As a result of injuries during the period when Plaintiff worked as a motor vehicle

operator for the New York City Department of Social Services “Homeless Division,” in 2019,

her condition has worsened. (Id.) She has a “handicap equipped” vehicle, and her sons or

caregivers drive her to medical appointments in New York City. (Id.) Plaintiff cannot “take

public transportation because [she] suffer[s] from anxiety.” (Id. at 6.) Plaintiff has “been force[d]

to spend money on Uber and Lyft because of not being able to park [her] handicap equipped

vehicle.” (Id.)

Plaintiff applied to the New York City Department of Transportation (DOT) for renewal

of her disabled person parking permit, but her application was denied; she states that her claims

arose on June 25, 2021 – the same day that she filed this complaint – “per phone call from

Catherine Messina,” whose position is not specified. (Id. at 6.) Plaintiff does not specify the basis

for the DOT’s denial of her application but states that “[t]he City of New York Department of

Health and Mental Hygiene (DOHMH) has refuse[d] to certify [Plaintiff] as permanently

disable[d] so [she] can have [a] permit parking.” (Id.)

Plaintiff refers to District Judge William H. Pauley III’s order in her employment

discrimination suit against the City of New York, Lawtone-Bowles v. City of New York, ECF

1:17-CV-8024, 45 (WHP) (S.D.N.Y. Feb. 15, 2019). In that action, Plaintiff sued the City of New

York under Title 1 of the ADA, asserting claims for, among other things, failing to accommodate

her disability. The City of New York moved to dismiss Plaintiff’s second amended complaint,

and Judge Pauley held, in relevant part, as follows:

At this early stage in the litigation, a pro se complaint must be given the benefit of

the doubt, and however inartfully pleaded, must be held to less stringent standards

than formal pleadings drafted by lawyers.” Erickson v. Pardus, 551 U.S. 89, 94

(2007). The Complaint sets forth sufficient facts to plausibly suggest that DHS

personnel could have taken action to accommodate Lawtone-Bowles’s disability

and simply failed to do so. Thus, the City’s motion to dismiss Lawtone-Bowles’s

failure to accommodate claims is denied.

Lawtone-Bowles, ECF17-CV-8024, 45, at 12.

In the February 15, 2019 order, Judge Pauley dismissed with prejudice Plaintiff’s federal,

state, and city law claims for discrimination, hostile work environment, and retaliation, and

denied, in part, the motion to dismiss, solely as to the failure-to-accommodate claim. Thereafter,

the parties settled as to the remaining claim, and the action was discontinued. Lawtone-Bowles,

ECF 17-CV-8024, 56.

Here, Plaintiff seeks damages and asks that “Judge Pauley[’s] order be enforced by all the

defendants to provide [her] with reasonable accommodations without restrictions.” (ECF 2 at 6.)

DISCUSSION

Plaintiff argues that New York City should have provided her with “reasonable

accommodations” for her disability by renewing her disabled person parking permit, and the

Court therefore construes her claim as arising under Title II of the ADA, 42 U.S.C. §§ 12131–

12134, which prohibits discrimination by public entities in the provision or operation of public

services, programs, or activities. 1 See Tennessee v. Lane, 541 U.S. 509, 516-17 (2004). More

specifically, the Court understands that Plaintiff is asserting that she is entitled to a reasonable

modification to New York City’s rules and procedures for obtaining a Special Vehicle

1 Plaintiff’s claim that she was denied a Special Vehicle Permit does not arise under Title

I of the ADA because, unlike her prior suit before Judge Pauley, these claims are unrelated to

Plaintiff’s employment. These claims also do not arise under Title III of the ADA, because a

parking permit is not a public accommodation. See 42 U.S.C. § 12181(7) (defining public

accommodations).

Identification Parking Permit (“Special Vehicle Permit”).2

A. Title II of the ADA

Title II defines “public entity” to include state and local governments, as well as their

agencies and instrumentalities. Lane, 541 U.S. at 517 (citing 42 U.S.C. § 12131(1)). It defines a

qualified individual with a disability as “an individual with a disability who, with or without

reasonable modifications to rules, policies, or practices, the removal of architectural,

communication, or transportation barriers, or the provision of auxiliary aids and services, meets

the essential eligibility requirements for the receipt of services or the participation in programs or

activities provided by a public entity.” 42 U.S.C. § 12131(2). Title II’s enforcement provision

incorporates by reference § 505 of the Rehabilitation Act of 1973, which authorizes private

citizens to bring suits for money damages. 42 U.S.C. § 1213; see Lane, 541 U.S. at 517.

Title II provides as follows:

[N]o qualified individual with a disability shall, by reason of such disability, be

excluded from participation in or be denied the benefits of the services, programs,

or activities of a public entity, or be subjected to discrimination by any such

entity.

42 U.S.C. § 12132.

To state a claim under Title II, a plaintiff must allege “‘(1) that she is a qualified

individual with a disability; (2) that she was excluded from participation in a public entity’s

services, programs or activities or was otherwise discriminated against by a public entity; and

(3) that such exclusion or discrimination was due to her disability.’” Tardif v. City of New York,

991 F.3d 394, 404 (2d Cir. 2021) (quoting Davis v. Shah, 821 F.3d 231, 259 (2d Cir. 2016)).

2 Under the rules of the City of New York, “Special Vehicle Identification Parking

Permits (SVIPP) [are] also known as Parking Permits for People with Disabilities (PPPD).” Title

24, RCNY, §16-01.

Disability for purposes of the ADA is construed broadly “in favor of expansive

coverage.” 28 C.F.R. § 35.108; Woolf v. Strada, 949 F.3d 89, 94 (2d Cir. 2020) (“The principal

purpose of the [amendments to the ADA in the] ADAAA was to overrule the Supreme Court’s

arguably narrow interpretation of what constitutes an ADA-qualifying disability . . . and to make

clear that the substantial-limitation requirement in the definition of ‘disability’ is not an exacting

one.”). Disability includes having a “physical or mental impairment that substantially limits one

or more of the major life activities,” § 35.108(a)(1)(i), having a “record of such impairment,”

§ 35.108(a)(1)(ii), or “[b]eing regarded as having such an impairment,” § 35.108(a)(1)(iii).

A plaintiff may base a Title II claim on any of three theories of liability: disparate

treatment (intentional discrimination), disparate impact, or failure to make a reasonable

accommodation. See Fulton v. Goord, 591 F.3d 37, 43 (2d Cir. 2009). “[T]he ADA’s reasonable

modification requirement contemplates modification to state laws, thereby permitting preemption

of inconsistent state laws, when necessary to effectuate Title II’s reasonable modification

provision.” Mary Jo C. v. New York State & Loc. Ret. Sys., 707 F.3d 144, 163 (2d Cir. 2013). A

reasonable modification is one that, among other things, does not “fundamentally alter the nature

of the service, program, or activity.” Powell v. National Bd. of Medical Examiners, 364 F.3d 79,

88 (2d Cir. 2004); see also PGA Tour, Inc. v. Martin, 532 U.S. 661 (2001) (reasoning that

disabled golfer’s use of golf cart would not fundamentally alter athletic event because the

essence of golf is “shot-making” and rule requiring walking was peripheral).

B. Plaintiff’s request for a Special Vehicle Permit

Defendant City of New York, as a local government, is a “public entity” subject to suit

under Title II of the ADA. See 42 U.S.C. § 12131(1)(A). Plaintiff alleges that she is permanently

disabled with knee problems and fibromyalgia, and she includes facts about how this interferes

with her sleep, memory, mood, and mobility. (ECF 2 at 5.) The Court assumes without deciding

that at this stage, Plaintiff adequately pleads that she has a disability within the meaning of the

ADA.

It is unclear, however, if Plaintiff is a “qualified individual” who either (1) “meets the

essential eligibility requirements,” 42 U.S.C. § 12131(2), for participation in the Special Vehicle

Permit program, or (2) could do so with “reasonable modifications to rules, policies, or

practices,” id.

NYC does not have on-street parking spaces reserved for disabled individuals; instead,

NYC extends additional on-street parking privileges for individuals who meet DOHMH

regulations, allowing Special Vehicle Permit holders to park in areas prohibited to the general

public. 34 RCNY § 4-08(d)(3); 24 RCNY, Ch.16. The New York City Charter sets forth rules for

awarding disabled people Special Vehicle Permits for New York City:

The [DOT] commissioner shall issue a special vehicle identification parking

permit to a New York city resident who requires the use of a private automobile

for transportation and to a non-resident who requires the use of a private

automobile for transportation to a school in which such applicant is enrolled or to

a place of employment, when such person has been certified by the department of

health and mental hygiene or a provider designated by the department or the

department of health and mental hygiene, who shall make such certification in

accordance with standards and guidelines prescribed by the department or the

department of health and mental hygiene, as having a permanent disability

seriously impairing mobility.

N.Y.C. Charter § 2903(a)(15)(a). An individual whose application for a Special Vehicle Permit is

denied may appeal DOHMH’s denial of certification “within thirty business days of service of

the decision denying the certification upon the applicant, on a form received with the decision.”

Title 24, RCNY Ch. 16, § 16-05. The determination of such an appeal is final “when it is adopted

by the [DOHMH].” (Id.)

Here, Plaintiff alleges that she resides outside New York City (ECF 2 at 2); she is on

leave from her employment (ECF 1 at 1); and DOHMH “has refuse[d] to certify [her] as

permanently disabled” 3 (ECF 2 at 5). Plaintiff does not plead facts about the basis for

DOHMH’s denial of certification, whether she appealed, or whether a final decision has issued

on appeal.4

An applicant need not meet all of a program’s “formal legal eligibility requirements” to

be a qualified individual – only the essential ones. Mary Jo C., 707 F.3d at 161 (“[T]he district

court’s view that the ADA’s reference to ‘essential eligibility requirements’ necessarily refers to

each and every formal legal eligibility requirement imposed for participation in a public program

or benefit is mistaken.”). Here, it is unclear on what basis the DOT denied Plaintiff a Special

Vehicle Permit – whether it was because she did not meet requirements that applicants live,

work, or study in New York City, or because the DOHMH denied Plaintiff certification, or for

some other reason or combination of reasons. Plaintiff thus has not pleaded sufficient facts to set

forth the nature of her challenge to New York City’s Special Vehicle Permit program.

3 The conditions that constitute “permanent disabilities that seriously impair mobility” for

purposes of § 2903(a)(15)(a) of the New York City Charter, are set forth in the Rules of the City

of New York, Title 24, Ch. 16, § 16-02. Qualifying disabilities include “(a) Complete monoplegia

or paraplegia of lower extremities; (b) Above ankle amputation of lower extremities, at the

discretion of the examining physician. Well-fitted below the knee prosthesis with normal

ambulatory gait should not routinely be regarded as mobility impaired. (c) Arthritis of two major

weight bearing joints [together with additional listed conditions] . . . .” Title 24, RCNY Ch. 16,

§ 16-02.

New York State has its own criteria for disabled parking permits. To qualify for a New

York State permit, an individual must: have limited or no use of one or both legs; have a neuro-

muscular dysfunction which severely limits mobility; have another physical or mental disability

which makes the use of public transportation difficult; or be legally blind. N.Y. Veh. & Traffic

Law § 404A.

4 Exhaustion requirements can be excused when exhaustion would be futile because the

administrative procedures do not provide an adequate remedy. Cave v. E. Meadow Union Free

Sch. Dist., 514 F.3d 240, 249 (2d Cir. 2008). Here, Plaintiff has not pleaded facts showing that it

would be futile to appeal DOHMH’s denial of medical certification. It is unclear whether, on

appeal, be able to establish her eligibility for the parking permit program.

Moreover, to successfully plead a claim for failure to make a reasonable accommodation,

a plaintiff must also suggest a plausible method for remedying that lack of access to a given

government resource. Henrietta D. v. Bloomberg, 331 F.3d 261, 280 (2d Cir. 2003). In Meekins v.

City of New York, 524 F. Supp. 2d 402 (2007), for example, plaintiffs brought a putative class

action under Title II of the ADA on behalf of disabled persons who held disability parking

permits issued by a government entity, but who did not qualify for the New York City Special

Vehicle Permit because they did not live, work, or study in New York City. Class members were

seeking reasonable access to medical and cultural resources and programs in New York City –

not asking to be granted permits under New York City’s program. Plaintiffs proposed that

members of the class be permitted to park for a limited amount of time in spaces made available

to Special Vehicle Permit holders. The district court reasoned that, by suggesting a “plausible

accommodation, the costs of which, facially, do not clearly exceed its benefits,” the plaintiffs had

made out a prima facie showing that a reasonable accommodation was available. Id. at 109

(relying on Henrietta D., 331 F.3d at 280). Because it required factual development to resolve

whether a proposed accommodation would be unduly difficult to implement, the district court in

Meekins denied the defendant’s motion to dismiss the reasonable accommodation claim.

Here, Plaintiff relies on the November 2019 decision in her employment discrimination

suit against the City of New York, and asks that “Judge Pauley[’s] order be enforced by all the

defendants to provide [her] with reasonable accommodations without restrictions.” (ECF 2 at 6.)

On its face, Plaintiff’s request that Defendants provide “accommodations without restrictions” is

insufficient to show that a reasonable accommodation is available. To the extent that Plaintiff

asks that Defendants grant her a permit whether or not she meets the medical or other criteria, or

that the City of New York alter its medical criteria, this is insufficient to allege that a reasonable

accommodation that would not fundamentally alter the program is available. See Doe v.

Pfrommer, 148 F.3d 73, 84 (2d Cir. 1998) (holding that the ADA does not “establish an

obligation to meet a disabled person’s particular needs vis-à-vis the needs of other [disabled]

individuals.”).5 For all of these reasons, Plaintiff fails to state a claim on which relief can be

granted under Title II of the ADA.

LEAVE TO AMEND

Plaintiff proceeds in this matter without the benefit of an attorney. District courts

generally should grant a self-represented plaintiff an opportunity to amend a complaint to cure its

defects, unless amendment would be futile. See Hill v. Curcione, 657 F.3d 116, 123-24 (2d Cir.

2011); Salahuddin v. Cuomo, 861 F.2d 40, 42 (2d Cir. 1988). Indeed, the Second Circuit has

cautioned that district courts “should not dismiss [a pro se complaint] without granting leave to

amend at least once when a liberal reading of the complaint gives any indication that a valid

claim might be stated.” Cuoco v. Moritsugu, 222 F.3d 99, 112 (2d Cir. 2000) (quoting Gomez v.

USAA Fed. Sav. Bank, 171 F.3d 794, 795 (2d Cir. 1999)). Because Plaintiff may be able to allege

additional facts to state a valid claim under the ADA, the Court grants Plaintiff 60 days’ leave to

amend her complaint to detail her claims.

Plaintiff is granted leave to amend her complaint to provide more facts about her claims.

In the “Statement of Claim” section of the amended complaint form, Plaintiff must provide a

short and plain statement of the relevant facts supporting each claim against each defendant. If

Plaintiff has an address for any named defendant, Plaintiff must provide it. Plaintiff should

5 If Plaintiff is alleging that she should be awarded a permit without meeting medical

criteria, such allegations also do not satisfy the causation requirement. See Tardif, 991 F.3d at

405 (plaintiffs must establish that their “disabilities were a substantial cause of their inability to

obtain services,” rather than “so remotely or insignificantly related to their disabilities as not to

be ‘by reason’ of them”).

include all of the information in the amended complaint that Plaintiff wants the Court to consider

in deciding whether the amended complaint states a claim for relief. That information should

include:

a) the names and titles of all relevant people;

b) a description of all relevant events, including what each defendant did or failed to do,

the approximate date and time of each event, and the general location where each

event occurred;

c) a description of the injuries Plaintiff suffered; and

d) the relief Plaintiff seeks, such as money damages, injunctive relief, or declaratory

relief.

Essentially, Plaintiff’s amended complaint should tell the Court: who violated her

federally protected rights and how; when and where such violations occurred; and why Plaintiff

is entitled to relief.

Because Plaintiff’s amended complaint will completely replace, not supplement, the

original complaint, any facts or claims that Plaintiff wants to include from the original complaint

must be repeated in the amended complaint. The Court also notes that although the DOHMH can

be sued in its own name, NYC Charter Ch. 22, § 564 (“The department may sue and be sued in

and by the proper name of ‘Department of Health and Mental Hygiene of the City of New

York’ . . .”), most New York City agencies cannot and must be sued in the name of the City of

New York, N.Y. City Charter ch. 17, § 396.

CONCLUSION

Plaintiff is granted leave to file an amended complaint that complies with the standards

set forth above. Plaintiff must submit the amended complaint to this Court’s Pro Se Intake Unit

within sixty days of the date of this order, caption the document as an “Amended Complaint,”

and label the document with docket number 21-CV-5620 (LTS). An Amended Complaint form is

attached to this order. No summons will issue at this time. If Plaintiff fails to comply within the

time allowed, and she cannot show good cause to excuse such failure, the complaint will be

dismissed for failure to state a claim upon which relief may be granted. See 28 U.S.C.

§ 1915(e)(2)(B)(ii).

The Court certifies under 28 U.S.C. § 1915(a)(3) that any appeal from this order would

not be taken in good faith, and therefore in forma pauperis status is denied for the purpose of an

appeal. Cf. Coppedge v. United States, 369 U.S. 438, 444-45 (1962) (holding that an appellant

demonstrates good faith when he seeks review of a nonfrivolous issue). The Clerk of Court is

directed to mail a copy of this order to Plaintiff and note service on the docket.

SO ORDERED.

Dated: July 12, 2021

New York, New York

/s/ Laura Taylor Swain

LAURA TAYLOR SWAIN

Chief United States District Judge

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF NEW YORK

_____CV_______________

(Include case number if one has been

Write the full name of each plaintiff.

assigned)

AMENDED

-against-

COMPLAINT

Do you want a jury trial?

☐ Yes ☐ No

Write the full name of each defendant. If you need more

space, please write “see attached” in the space above and

attach an additional sheet of paper with the full list of

names. The names listed above must be identical to those

contained in Section II.

NOTICE

The public can access electronic court files. For privacy and security reasons, papers filed

with the court should therefore 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.

See Federal Rule of Civil Procedure 5.2.

I. BASIS FOR JURISDICTION

Federal courts are courts of limited jurisdiction (limited power). Generally, only two types of

cases can be heard in federal court: cases involving a federal question and cases involving

diversity of citizenship of the parties. Under 28 U.S.C. § 1331, a case arising under the United

States Constitution or federal laws or treaties is a federal question case. Under 28 U.S.C. § 1332,

a case in which a citizen of one State sues a citizen of another State or nation, and the amount

in controversy is more than $75,000, is a diversity case. In a diversity case, no defendant may

be a citizen of the same State as any plaintiff.

What is the basis for federal-court jurisdiction in your case?

☐ Federal Question

☐ Diversity of Citizenship

A. If you checked Federal Question

Which of your federal constitutional or federal statutory rights have been violated?

B. If you checked Diversity of Citizenship

1. Citizenship of the parties

Of what State is each party a citizen?

The plaintiff , , is a citizen of the State of

(Plaintiff’s name)

(State in which the person resides and intends to remain.)

or, if not lawfully admitted for permanent residence in the United States, a citizen or

subject of the foreign state of

.

If more than one plaintiff is named in the complaint, attach additional pages providing

information for each additional plaintiff.

If the defendant is an individual:

The defendant, , is a citizen of the State of

(Defendant’s name)

or, if not lawfully admitted for permanent residence in the United States, a citizen or

subject of the foreign state of

.

If the defendant is a corporation:

The defendant, , is incorporated under the laws of

the State of

and has its principal place of business in the State of

or is incorporated under the laws of (foreign state)

and has its principal place of business in .

If more than one defendant is named in the complaint, attach additional pages providing

information for each additional defendant.

II. PARTIES

A. Plaintiff Information

Provide the following information for each plaintiff named in the complaint. Attach additional

pages if needed.

First Name Middle Initial Last Name

Street Address

County, City State Zip Code

Telephone Number Email Address (if available)

B. Defendant Information

To the best of your ability, provide addresses where each defendant may be served. If the

correct information is not provided, it could delay or prevent service of the complaint on the

defendant. Make sure that the defendants listed below are the same as those listed in the

caption. Attach additional pages if needed.

Defendant 1:

First Name Last Name

Current Job Title (or other identifying information)

Current Work Address (or other address where defendant may be served)

County, City State Zip Code

Defendant 2:

First Name Last Name

Current Job Title (or other identifying information)

Current Work Address (or other address where defendant may be served)

County, City State Zip Code

Defendant 3:

First Name Last Name

Current Job Title (or other identifying information)

Current Work Address (or other address where defendant may be served)

County, City State Zip Code

Defendant 4:

First Name Last Name

Current Job Title (or other identifying information)

Current Work Address (or other address where defendant may be served)

County, City State Zip Code

III. STATEMENT OF CLAIM

Place(s) of occurrence:

Date(s) of occurrence:

FACTS:

State here briefly the FACTS that support your case. Describe what happened, how you were

harmed, and what each defendant personally did or failed to do that harmed you. Attach

additional pages if needed.

INJURIES:

If you were injured as a result of these actions, describe your injuries and what medical

treatment, if any, you required and received.

IV. RELIEF

State briefly what money damages or other relief you want the court to order.

V. PLAINTIFF’S CERTIFICATION AND WARNINGS

By signing below, I certify to the best of my knowledge, information, and belief that: (1) the

complaint is not being presented for an improper purpose (such as to harass, cause

unnecessary delay, or needlessly increase the cost of litigation); (2) the claims are supported

by existing law or by a nonfrivolous argument to change 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 Federal Rule of Civil

Procedure 11.

I agree to notify the Clerk's Office in writing of any changes to my mailing address. 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.

Each Plaintiff must sign and date the complaint. Attach additional pages if necessary. If seeking to

proceed without prepayment of fees, each plaintiff must also submit an IFP application.

Dated Plaintiff’s Signature

First Name Middle Initial Last Name

Street Address

County, City State Zip Code

Telephone Number Email Address (if available)

I have read the Pro Se (Nonprisoner) Consent to Receive Documents Electronically:

☐ Yes ☐ No

If you do consent to receive documents electronically, submit the completed form with your

complaint. If you do not consent, please do not attach the form.