Opinion

Brown v. The City of New York

Court: District Court, S.D. New York
Filed: Aug 17, 2023
Cited by: 0 cases
Authority: More cited than 27.7%

“[D]istrict courts may dismiss an action sua sponte on limitations grounds in certain circumstances where the facts supporting the statute of limitations defense are set forth in the papers plaintiff himself submitted.” (internal quotation marks and citation omitted)

How later courts described this case

“[D]istrict courts may dismiss an action sua sponte on limitations grounds in certain circumstances where the facts supporting the statute of limitations defense are set forth in the papers plaintiff himself submitted.” (internal quotation marks and citation omitted)
under the prison mailbox rule, a motion is deemed filed when it is given to prison officials for mailing
holding that an appellant demonstrates good faith when he seeks review of a nonfrivolous issue
affirming sua sponte dismissal of complaint as frivolous on statute of limitations grounds

Written by the judges who cited it.

The opinion

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF NEW YORK

ARTHUR LAMAR BROWN,

Plaintiff,

23-CV-5924 (JGLC)

-against-

ORDER OF SERVICE

THE CITY OF NEW YORK, et al.,

Defendants.

JESSICA G. L. CLARKE, United States District Judge:

Plaintiff, who is currently detained at the North Infirmary Command (“NIC”) on Rikers

Island, brings this pro se action under 42 U.S.C. § 1983, alleging that Defendants violated his

federal constitutional rights and his rights under state law. By order dated August 14, 2023, the

Court granted Plaintiff’s request to proceed in forma pauperis (“IFP”), that is, without

prepayment of fees.1 For the reasons set forth below, the Court (1) requests that the named

defendants waive service of summons; (2) directs the New York City Department of Correction

(“DOC”) to assist Plaintiff in identifying the Doe defendants; (3) orders Plaintiff to show cause,

within 30 days of the day of this order, why his claims arising from events occurring before June

30, 2020, should be not dismissed as time-barred; and (4) denies Plaintiff’s request for

preliminary injunctive relief without prejudice to renewal at a later time.

DISCUSSION

A. Waiver of Service

The Clerk of Court is directed to notify the New York City Department of Correction and

the New York City Law Department of this order. The Court requests that the following

1 Prisoners are not exempt from paying the full filing fee even when they have been

granted permission to proceed IFP. See 28 U.S.C. § 1915(b)(1).

Defendants waive service of summons: (1) the City of New York; (2) NIC Warden (or former

Warden) Ronald Miller; (3) Captain Moses #1881; (4) Correction Officer Mohamed #7586;

(5) Correction Officer Omer #16031; (6) Correction Officer Porter #7592; (7) Correction Officer

Wu #11367; (8) Correction Officer Kendall #9028; (9) Correction Officer Mendelsohn #17787;

(10) Adjudication Captain Vasquez #404; and (11) Chief of Security Charlton Lemon.

B. Valentin Order

Under Valentin v. Dinkins, a pro se litigant is entitled to assistance from the district court

in identifying a defendant. 121 F.3d 72, 76 (2d Cir. 1997). In the complaint, Plaintiff supplies

sufficient information to permit DOC to identify the three Jane Doe Adjudication Captains who

presided over Plaintiff’s administrative hearings on the dates provided in the complaint. It is

therefore ordered that the New York City Law Department, which is the attorney for and agent of

DOC, must ascertain the identity and badge number of each Jane Doe whom Plaintiff seeks to

sue here and the address where the defendant may be served.2 The Law Department must

provide this information to Plaintiff and the Court within 60 days of the date of this order.

Within 30 days of receiving this information, Plaintiff must file an amended complaint

naming the Jane Doe defendants. The amended complaint will replace, not supplement, the

original complaint. An amended complaint form that Plaintiff should complete is attached to this

order. Once Plaintiff has filed an amended complaint, the Court will screen the amended

complaint and, if necessary, issue an order asking the newly named defendants to waive service.

2 If the Doe defendant is a current or former DOC employee or official, the Law

Department should note in the response to this order that an electronic request for a waiver of

service can be made under the e-service agreement for cases involving DOC defendants, rather

than by personal service at a DOC facility. If the Doe defendant is not a current or former DOC

employee or official, but otherwise works or worked at a DOC facility, the Law Department must

provide a residential address where the individual may be served.

C. Timeliness

In his complaint, Plaintiff asserts claims under 42 U.S.C. § 1983 arising from events that

occurred between May 2019 and the present. It appears that some of Plaintiff’s claims are time-

barred. The statute of limitations for Section 1983 claims is found in the “general or residual

[state] statute [of limitations] for personal injury actions.” Pearl v. City of Long Beach, 296 F.3d

76, 79 (2d Cir. 2002) (quoting Owens v. Okure, 488 U.S. 235, 249-50 (1989)). In New York, that

period is three years. See N.Y. C.P.L.R. § 214(5). Section 1983 claims generally accrue when a

plaintiff knows or has reason to know of the injury that is the basis of the claim. Hogan v.

Fischer, 738 F.3d 509, 518 (2d Cir. 2013). Plaintiff filed this action when he placed the

complaint into the prison mailing system on June 20, 2023. See Walker v. Jastremski, 430 F.3d

560, 562-64 (2d Cir. 2005) (under the prison mailbox rule, a motion is deemed filed when it is

given to prison officials for mailing). Plaintiff’s claims arising from events occurring before June

30, 2020, are therefore untimely.

The doctrine of equitable tolling permits a court, “under compelling circumstances, [to]

make narrow exceptions to the statute of limitations in order ‘to prevent inequity.’” In re U.S.

Lines, Inc., 318 F.3d 432, 436 (2d Cir. 2003) (citation omitted). The statute of limitations may be

equitably tolled, for example, when a defendant fraudulently conceals from a plaintiff the fact

that the plaintiff has a cause of action, or when the plaintiff is induced by the defendant to forego

a lawsuit until the statute of limitations has expired. See Pearl, 296 F.3d at 82-83. In addition,

New York law provides that where a person “is under a disability because of . . . insanity at the

time the cause of action accrues,” the applicable statute of limitations will be tolled. N.Y.

C.P.L.R. § 208; Gardner v. Wansart, No. 05-CV-3351, 2006 WL 2742043, at *5 n.4 (S.D.N.Y.

Sept. 25, 2006) (although mental illness is on its own insufficient for equitable tolling purposes,

tolling is appropriate if a plaintiff is insane at the time the cause of action accrues and is “unable

to protect [his] legal rights because of an overall inability to function in society”). New York also

provides by statute for other circumstances in which a limitations period may be tolled. See, e.g.,

N.Y. C.P.L.R. § 204(a) (where commencement of an action has been stayed by court order), id. at

§ 204 (where a dispute has been submitted to arbitration but is ultimately determined to be non-

arbitrable), id. at § 207(3) (defendant is outside New York at the time the claim accrues), id. at

§ 208 (plaintiff is disabled by infancy or insanity), id. at § 210 (death of plaintiff or defendant).

Plaintiff does not provide any facts suggesting that the statute of limitations should be

equitably tolled in this case. Because the failure to file an action within the limitations period is

an affirmative defense, a plaintiff is generally not required to plead that the case is timely filed.

See Abbas v. Dixon, 480 F.3d 636, 640 (2d Cir. 2007). Dismissal is appropriate, however, where

the existence of an affirmative defense, such as the statute of limitations, is plain from the face of

the pleading. See Walters v. Indus. and Commercial Bank of China, Ltd., 651 F.3d 280, 293 (2d

Cir. 2011) (“[D]istrict courts may dismiss an action sua sponte on limitations grounds in certain

circumstances where the facts supporting the statute of limitations defense are set forth in the

papers plaintiff himself submitted.” (internal quotation marks and citation omitted)); Pino v.

Ryan, 49 F.3d 51, 53 (2d Cir. 1995) (affirming sua sponte dismissal of complaint as frivolous on

statute of limitations grounds); see also Abbas, 480 F.3d at 640 (concluding that district court

should grant notice and opportunity to be heard before dismissing complaint sua sponte on

statute of limitations grounds).

The facts alleged by Plaintiff do not justify equitable tolling of his claims. The Court

therefore directs Plaintiff to show cause within 30 days of the date of this order why his

Section 1983 claims arising from events that occurred before June 30, 2020, should not be

dismissed as untimely. Plaintiff should allege any facts demonstrating that these claims are

timely or that the doctrine of equitable tolling should apply to these claims. A declaration form is

attached to this order.

D. Plaintiff’s Motion for Preliminary Injunctive Relief

Along with the complaint, Plaintiff submitted a proposed unsigned order to show cause

for a preliminary injunction and temporary restraining order, as well as an affidavit in support of

his motion. (ECF Nos. 4, 5.) To obtain preliminary injunctive relief, Plaintiff must show: (1) that

he is likely to suffer irreparable harm and (2) either (a) a likelihood of success on the merits of

his case or (b) sufficiently serious questions going to the merits to make them a fair ground for

litigation and a balance of hardships tipping decidedly in his favor. See UBS Fin. Servs., Inc. v.

W.V. Univ. Hosps., Inc., 660 F. 3d 643, 648 (2d Cir. 2011) (citation and internal quotation marks

omitted); Wright v. Giuliani, 230 F.3d 543, 547 (2000). Preliminary injunctive relief “is an

extraordinary and drastic remedy, one that should not be granted unless the movant, by a clear

showing, carries the burden of persuasion.” Moore v. Consol. Edison Co. of N.Y., Inc., 409 F.3d

506, 510 (2d Cir. 2005) (internal quotation marks and citation omitted).

At this stage in the proceedings, Plaintiff’s submissions do not demonstrate: (1) a

likelihood of success on the merits, or (2) sufficiently serious questions going to the merits to

make them a fair ground for litigation and a balance of hardships tipping decidedly in his favor.

Accordingly, Plaintiff’s request for an order to show cause (ECF No. 4) is denied without

prejudice to renewal at a later date.

E. NYLAG Clinic

Plaintiff may consult the legal clinic in this District that assists people who are parties in

civil cases and do not have lawyers. The Clinic is run by a private organization called the New

York Legal Assistance Group (“NYLAG”); it is not part of, or run by, the court (and, among

other things, therefore cannot accept filings on behalf of the court, which must still be made by

any pro se party through the Pro Se Intake Unit).

To receive limited-scope assistance from the Clinic, Plaintiff may mail a signed retainer

and intake form to the NYLAG Pro Se Clinic at 40 Foley Square, LL22, NY, NY 10007. Once

the paperwork is received, the Clinic will coordinate contact with the litigant. Once the

paperwork is received, it may take up to two weeks for the Clinic to contact the litigant. Copies

of the Clinic’s flyer, retainer, and intake form are attached to this order.

CONCLUSION

The Clerk of Court is directed to electronically notify the New York City Department of

Correction and the New York City Law Department of this order. The Court requests that the

following Defendants waiver service of summons: (1) the City of New York; (2) NIC Warden (or

former Warden) Ronald Miller; (3) Captain Moses #1881; (4) Correction Officer Mohamed

#7586; (5) Correction Officer Omer #16031; (6) Correction Officer Porter #7592; (7) Correction

Officer Wu #11367; (8) Correction Officer Kendall #9028; (9) Correction Officer Mendelsohn

#17787; (10) Adjudication Captain Vasquez #404; and (11) Chief of Security Charlton Lemon.

The Clerk of Court is further directed to mail a copy of this order and the complaint to the

New York City Law Department at: 100 Church Street, New York, N.Y. 10007. An “Amended

Complaint” form is attached to this order.

The Court directs Plaintiff, within 30 days, to show cause why his claims arising from

events that occurred before June 30, 2020, should not be dismissed as time-barred. A declaration

form is attached to this order.

The Court denies Plaintiff’s request for an order to show cause without prejudice to

renewal at a later date. (ECF No. 4.)

Copies of the NYLAG Clinic’s flyer, retainer, and intake form are also attached to this

order.

The Clerk of Court is also directed to mail an information package to Plaintiff.

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).

SO ORDERED.

Dated: August 17, 2023

New York, New York O ice Clan ko

7 peewee A AN __

JESSICA G. L. CLARKE

United States District Judge

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF NEW YORK

(In the space above enter the full name(s) of the plaintiff(s).) AMENDED

COMPLAINT

-against- under the Civil Rights Act,

42 U.S.C. § 1983

Jury Trial: O Yes oO No

(check one)

Ci CD

(dn the space above enter the full name(s) of the defendant(s). Ifyou

cannot fit the names of all of the defendants in the space provided,

please write “see attached” in the space above and attach an

additional sheet of paper with the full list of names. The names

listed in the above caption must be identical to those contained in

Part I. Addresses should not be included here.)

I. Parties in this complaint:

A. List your name, identification number, and the name and address of your current place of

confinement. Do the same for any additional plaintiffs named. Attach additional sheets of paper

as necessary.

Plaintiff’ s Name

WH eee

Current Institution,

Address eee

B. List all defendants’ names, positions, places of employment, and the address where each defendant

may be served. Make sure that the defendant(s) listed below are identical to those contained in the

above caption. Attach additional sheets of paper as necessary.

Defendant No. 1 Name —s—aiesesesa (aes

Where Currently Employed eee

Address ee

Address __________________________________________________________

_________________________________________________________________

Defendant No. 3 Name ___________________________________________ Shield #_________

Where Currently Employed __________________________________________

Address __________________________________________________________

_________________________________________________________________

Who did

what? Defendant No. 4 Name ___________________________________________ Shield #_________

Where Currently Employed __________________________________________

Address __________________________________________________________

_________________________________________________________________

Defendant No. 5 Name ___________________________________________ Shield #_________

Where Currently Employed __________________________________________

Address __________________________________________________________

_________________________________________________________________

II. Statement of Claim:

State as briefly as possible the facts of your case. Describe how each of the defendants named in the

caption of this complaint is involved in this 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 you intend to allege a number of related claims,

number and set forth each claim in a separate paragraph. Attach additional sheets of paper as necessary.

A. In what institution did the events giving rise to your claim(s) occur?

_______________________________________________________________________________

B. Where in the institution did the events giving rise to your claim(s) occur?

_______________________________________________________________________________

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

_______________________________________________________________________________

D. Facts:__________________________________________________________________________

_____________________________________________________________________________________

What

happened _____________________________________________________________________________________

_____________________________________________________________________________________

Was _____________________________________________________________________________________

anyone

else _____________________________________________________________________________________

involved?

_____________________________________________________________________________________

Who else

saw what

happened? III. Injuries:

If you sustained injuries related to the events alleged above, describe them and state what medical

treatment, if any, you required and received.

______________________________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________________

IV. Exhaustion of Administrative Remedies:

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.

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

Yes ____ No ____

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 claim(s)?

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?

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, about the events described in this complaint, where did you file the

grievance?

_______________________________________________________________________________

1. Which claim(s) in this complaint did you grieve?

______________________________________________________________________________

_______________________________________________________________________________

2. What was the result, if any?

_______________________________________________________________________________

3. What steps, if any, did you take to appeal that decision? 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 informed any 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.

V. Relief:

State what you want the Court to do for you (including the amount of monetary compensation, if any, that

you are seeking and the basis for such amount).

Rev. 01/2010

VI. Previous lawsuits:

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 | through 7 below. (If

there is more than one lawsuit, describe the additional lawsuits on another sheet of paper, using

the same format.)

1. Parties to the previous lawsuit:

Plaintiff

Defendants

2.Court (if federal court, name the district; if state court, name the county)

3. Docket or Index number

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 there

judgment in your favor? Was the case appealed?)

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

Yes No

s —_——

D. If your answer to C is YES, describe each lawsuit by answering questions | through 7 below. (If

there is more than one lawsuit, describe the additional lawsuits on another piece of paper, using

the same format.)

1. Parties to the previous lawsuit:

Plaintiff

Defendants

2. Court (if federal court, name the district; if state court, name the county)

3. Docket or Index number

4, Name of Judge assigned to your case. eee

5. Approximate date of filing lawsuit

Rev. 01/2010

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 there

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

________________________________________________________________________

_________________________________________________________________________

I declare under penalty of perjury that the foregoing is true and correct.

Signed this day of , 20 .

Signature of Plaintiff _____________________________________

Inmate Number _____________________________________

Institution Address _____________________________________

_____________________________________

Note: All plaintiffs named in the caption of the complaint must date and sign the complaint and provide

their inmate numbers and addresses.

I declare under penalty of perjury that on this _____ day of _________________, 20__, I am delivering

this complaint to prison authorities to be mailed to the Pro Se Office of the United States District Court for

the Southern District of New York.

Signature of Plaintiff: _____________________________________

Y | A G Since 1990, NYLAG has provided free civil legal services to

New Yorkers who cannot afford private attorneys.

New York ME Legal Assistance Group

Free Legal Assistance for Self-Represented Incarcerated

Civil Litigants in Federal District Court

e NYLAG Legal Clinic for Pro Se Litigants in The Clinic Can:

Southern District of New York is a free legal

staffed by attorneys, law students, and « Assist with amending complaints and respondin;

to assist those who are representing motions to dismiss;

or planning to represent themselves, = Represent litigants for settlement purposes and,

incarcerated litigants, in civil lawsuits in limited circumstances, for depositions;

Southern District of New York federal court, = Assist with written discovery;

habeas cases. The clinic is not part of or = Recruit pro bono counsel for depositions and tris

by the court. and

en if a litigant has consulted with Clinic staff, = Assist with oppositions to summary judgment.

they retain other counsel and that counsel . .

Clinic staff cannot assist with habeas cases «

a notice of appearance, they remain

: criminal matters.

are responsible for doing

is necessary in connection with the case; NyT_AG may also be unable to assist if it determines

still oe co a a ' its professional legal judgement, that (i) you have

petay bg Keo mas met ay Dame refused to cooperate with the Clinic’s counsel or foll

Moynihan Courthouse, 40 Foley Square, way sass .

□ : the Clinic’s advice; (ii) any assistance would be

York, New York, or by following the court’s . □□

i A J □ unreasonably difficult for NYLAG to carry out; or (ii

for filing via email as a pro se litigant. . . .

your case is or will become frivolous, unreasonable,

groundless, or without merit.

the Clinic:

the clinic and request a copy of our retainer, please call (212) 659-6190 and leave a message or

to us at the following address:

NYLAG Legal Clinic for Pro Se Litigants

Thurgood Marshall Federal Courthouse

Room LL22

40 Foley Square

New York, NY 10007

mail a signed retainer back to the clinic at the above address. Once the paperwork is received, clinic

will contact you. It may take up to two weeks.

Disclaimer: The information contained herein is for informational purposes only and is not legal advice or a substitute for legal counsel,

nor does it constitute advertising or a solicitation.

New York EEE Legal Assistance Group

LEGAL CLINIC FOR PRO SE LITIGANTS IN THE

SOUTHERN DISTRICT OF NEW YORK

LIMITED SCOPE LEGAL ASSISTANCE RETAINER AGREEMENT

retain the New York Legal Assistance Group (NYLAG) to provide you with limited scope legal assistance

its Legal Clinic for Pro Se Litigants in the Southern District of New York (Clinic) under the terms set

forth below.

I. LIMITS OF ASSISTANCE

The Clinic agrees to provide only limited scope legal assistance in connection with your matter.

This means that:

@ You remain a self-represented (pro se) litigant and are responsible for all aspects of your case. NYLAG 1s

not your attorney of record in this matter. In the event that you are or become a party to a case in the

Southern District of New York or any other forum, NYLAG will not enter an appearance or otherwise act

on your behalf without expressly agreeing to do so and entering into a separate signed agreement with

you. NYLAG has no obligation to enter into any such agreement.

NYLAG has sole discretion to determine the specific type of services provided. These services may

include providing advice and counsel about your case, explaining court orders and procedures, reviewing

and commenting on your drafts, assisting with drafting, and discussing strategy.

e@ This retainer covers an initial consultation only. NYLAG can stop assisting you with this matter at any

time for any reason consistent with the New York Rules of Professional Conduct.

NYLAG has not agreed to represent or assist you on any other matter in the future. If NYLAG does agree

to any representation on another matter, then a separate signed retainer agreement will be necessary.

@ You may request but are not guaranteed subsequent appointments. NYLAG will only provide assistance

on subsequent appointments if it provides you with confirmation to you of such assistance, via email or

otherwise, with such additional assistance governed by the terms of this agreement, including that the

assistance is for that consultation only and that NYLAG has sole discretion to decide whether it will

provide any additional future consultations. You are responsible for and must meet all deadlines in your

case, regardless of whether you are able to have an appointment with the Clinic.

II. FREE ASSISTANCE, NON-ATTORNEY PROVIDERS, AND COMPETENCY

does not charge for this assistance. You may be assisted by law students and/or paralegals under the

supervision of an attorney consistent with the Rules of Professional Responsibility. NYLAG’s assistance does

guarantee success or any particular outcome but that NYLAG will provide competent assistance.

Your participation is entirely voluntary, and you are free to stop receiving NYLAG’s limited scope assistance at

any time. NYLAG may stop providing limited assistance at its sole discretion consistent with the New York

Rules of Professional Conduct. If NYLAG chooses to stop providing limited assistance, it will provide notice by

email, mail, or phone.

IV. CONFIDENTIALITY

NYLAG will take all reasonable steps to maintain any information you provide as confidential.

V. REVIEW AND CONSENT

By signing and writing today's date below, you indicate that you: have read and understand this agreement;

consent to the terms of this agreement; and understand the possible risks and benefits of proceeding with limited

scope assistance.

If you have questions or concerns, please indicate on this form and someone will arrange to speak with you.

________________________________ _________________

Signature Date

Once you have completed this form, please mail it and the completed

demographic form to the New York Legal Assistance Group, Pro Se

Clinic, 40 Foley Square, LL22, New York, NY 10007.

ole Pw

New York BE Legal Assistance Group

Name Date of Birth

Facility

Identification # Email (if available)

How did you hear about our clinic? (Circle One)

Pro Se Intake Office Order/Letter from the Judge Conference/Hearing with the Judge

Pro Se Information Package Website Friend/Family

Other

Ethnicity (Circle One)

Asian/Pacific Islander Hispanic Caucasian

African American Middle Eastern Decline to Answer

African Caribbean

Native American South Asian

Education Level (Circle One)

Grade or Less GED 2-4 years of College/Vocational School

Some high school College graduate Decline to Answer

High school graduate Graduate degree

Gender:

SDNY Case Number:

Once you have completed this form, please mail it and the completed

retainer to the New York Legal Assistance Group, Pro Se Clinic, 40

Foley Square, LL22, New York, NY 10007.

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF NEW YORK

Write the first and last name of each plaintiff or

petitioner.

Case No. CV

-against-

Write the first and last name of each defendant or

respondent.

DECLARATION

Briefly explain above the purpose of the declaration, for example, “in Opposition to Defendant’s

Motion for Summary Judgment,” or “in Response to Order to Show Cause.”

I, , declare under penalty of perjury that the

following facts are true and correct:

In the space below, describe any facts that are relevant to the motion or that respond to a court

order. You may also refer to and attach any relevant documents.

Attach additional pages and documents if necessary.

Executed on (date) Signature

Name Prison Identification # (if incarcerated)

Address City State Zip Code

Telephone Number (if available) E-mail Address (if available)

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.