FORM A FORM TO BE USED BY A PRISONER IN FILING A COMPLAINT UNDER 42 U.S.C. § 1983 IN THE UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF IOWA, /Alwstoplis (Bure) The hing Maw RESEWED (2 Torso mt — CLERK US. DISTRICT COURT ‘SOUTHERN: DISTRICT OF OWA. (Enter ahove the FULL name and inmate ‘numher of the plaintiff or plaintiffs in this action) vs COMPLAINT No. $16 CV = OOFII- REE-HCA Sheriff Bul Wel ad thy (Enter ahove the FULL name of each defendant in this action) (NOTE: If there is more than one plaintiff, the information in parts | and IT should he shown for EACH plaintiff hy name, using a separate sheet of paper. 1 Previous Lawsuits: ‘A. Have you hegun other lawsuits in State or Federal Court dealing with the same facts involved in this action or otherwise relating to your imprisonment? Yes( ) No(g*) B. _Ifyour answer to A is Yes, please answer questions I thru 7. (If there is more than ‘one lawsuit, descrihe the additional lawsuits on another sheet of paper, using the same outline.) I Parties to this previous lawsuit Plaintiffs, DefendantsMl. 2, Court (if Federal Court, name the district; if State Court, name the county) fA 3. Docket Number Nf A 4. Name of Judge to whom the case was assigned iv la 5. Disposition, if known (for example: Was the ease dismissed? Was it appealed? Is it still pending?) off 6. Approximate date of filing lawsuit N, 7. Approximate date of disposition 7 Place of Present content Letts Caatly Zp A. Is there a prisoner grievance procedure in this institution? Yes(@) No( ) B. Did you present the facts relating to your complaint in the state prisoner grievance procedure? Yes (} No( ) C. If your answer is Yes, I What steps did you take? Wrote 40 Tee Semsur, slerilf , felled greveuces, filled ovt hundreds 2. What was the result? + Kies N/A SheeCapt, WilliauS reforueel 3 (eters, No resus D. If your answer is No, explain why not E. If there is no prison grievance procedure in the institution, did you complain to prison authorities? Yes(/) No( ) F. If your answer is Yes, 1 What steps did you take? Ni* 2. What was the result? Parties H/q (In item A below, place your name in the first blank and place your present address in the second blank. Do the same for additional plaintiff(s), if any.) A. Name of Plaintitt_{- “hastepl c_(Brece) the Li — MaidAddress _dD* 7690 py 721 B. Additional plaintiffs at ({n item C below, place the full name of the defendant in the first blank, his official position in the second blank, and his place of employment in the third blank. Use item D for the names, positions, and places of employment of any additional defendants.) C. Defendant hen is employed as _.S at IV. Jurisdiction ‘This complaint is brought pursuant to 42 U.S.C. § 1983, and jurisdiction is based on 28 USC. § 1343. Plaintiffs) allege(s) the defendant(s) acted under color of state law with regard to the facts stated in part V of this complaint. V. Statement of Claim (State here as briefly as possibie the FACTS of your case. You MUST state exactly what each defendant personally did, or failed to do, which resulted in harm to you. Include also the names of other persons involved (for example, other inmates) and state the date and place of all events. Attach an extra sheet if necessary, and write the heading. PART V CONTINUED at the top of the sheet. Keep to the facts. Do not give any legal arguments or cite any cases.) Sec Atnclneut A"VI. (State hriefly exactly what you want the Court to do for you. Make no legal arguments. Do not cite cases or statntes.) cae f VII Statement Regarding Assistance in Preparing this Complaint ‘A. Did any person other than a named plaintiff in this action assist you in preparing this complaint? Yes ( ) No (¢) If your answer is Yes name the person who assisted you, C. 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