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IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN OF OHIO
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(ENTER ABOVE THE NAME OF THE PLAINTIFF IN THIS ACTION) \
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IF THE PLAINTIFF IS A IlP'QNER # . __ . r JAMES BOWNI! Clerk
CINCINNATI, OHIO
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(ENTER ABOVE THE NAME OF THE DEFENDANT IN THIS ACTION)
IF THERE ARE ADDITIONAL DEFENDANTS PLEASE LlST THEM: . M.J. BOWMAN
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COMPLAINT
L PARTIES TO THE ACTION:
PLAINTIFF: PLACE YOUR NAME AND ADDRESS ON THE LINES BELOW. THE
ADDRESS YOU GIVE MUST BE THE ADDRESS'THAT THE COURT MA Y
CONTACT YOU AND MAIL DOCUMENTS 1;0 YOU. A TELEPHONE
NUMBER IS REQUIRED .
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NAME FULL NAME PLEASE - PRINT
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'ADDRESS: STREET, CITY, STATE AND ZIP CODE'--
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TELEPHONE NUMBER
IF THERE ARE ADDITIONAL PLAINTIFFS IN THIS SUIT, A SEPARATE PIECE OF PAPER
SHOULD BE ATTACHED IMMEDIATELY BEHIND THIS PAGE WITH THEIR FULL NAMES,
ADDRESSES AND TELEPHONE NUMBERS. IF NO ADI?ITIONAL PLAINTIFFS EXJSTCONTfJ\.TUE
WITH THIS FORM,
PAGE 2 AND 3 OF THIS FORM DEAL ONLY WITH A PLAINTIFF THAT IS INCARCERATED
AT THE T1ME OF FILING THIS COMPLAINT. "
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Case: 1:11-cv-00793-SAS-SKB Doc #: 3 Filed: 12/08/11 Page: 1 of 6 PAGEID #: 11
IF YOU ARE A PRISONER FILING A CIVIL SUIT THE FOLLOVv1NG INFORl\1A TION IS
REQUIRED:
PREVIOUS LA WSUITS:
A. HA VE YOU BEG1JN OTHER LAWSUITS IN STATE OR FEDERAL COURT DEALING
WITH THE SAME FACTS INVOLVED IN THIS ACTION OR OTHERWISE RELATING
TO YOUR IMPRISONMENT? YES ( ) NO ( )
B. IF YOUR ANSWER TO A IS YES, DESCRIBE THE LA WSUIT IN THE SPACE BELOW.
(IF THERE IS MORE THAN ONE LAWSUIT, DESCRIBE THE ADDITIONAL
LAWSUITS ON ANOTHER PIECE OF PAPER, USING THE SAME OUTLINE.)
1. PARTIES TO THIS PREVIOUS LA WSUIT
PLAINTIFFS:
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DEFENDANTS:
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2. COURT (IF FEDERAL COURT, NAME THE DISTRICT: IF STATE COURT,
NAME THE COUNTY)
3, DOCKET NUMBER
4. NAME OF THE JUDGE TO WHOM THE CASE WAS ASSIGNED
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5, DISPOSITION (FOR EXAMPLE, WAS THE DISMISSED') WAS IT
APPEALED? IS IT-STiLL PENDING?) $1l \ "-.l tl; NJ..\
6, APPROXIMA TE DATE OF THE flUNG OF THE LA WSUIT
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7. APPROXIMATE DATE OF THE DISPOSITION
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Case: 1:11-cv-00793-SAS-SKB Doc #: 3 Filed: 12/08/11 Page: 2 of 6 PAGEID #: 12
PLACE OF PRESENT CONFINEMENT
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A. E AA PRISONER GRIEYANCE PROCEDURE IN THIS INSTITUTION?
YES

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B. DID YOU PRESENT THE FACTS RELATING TOlZQUR COMPLAINT IN THI SSTATE
PRISONER GRIEYANCE PROCEDURE? YES ( ) NO{\)
c. IF YOUR ANSWER IS YES:
D.
------..----- --
E. IF THERE IS NO PRISON GRlEVANCE PROCEDURE IN THIS INSTITUTION. DID
YOU COMPLAIN TO PRISON AUTHORITIES? .
F. IF YOUR ANSWER IS YES:
I. WHATSTEPSbIDYOUTAKE? \ ..
2. WHAT WAS THE RESULT?
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Case: 1:11-cv-00793-SAS-SKB Doc #: 3 Filed: 12/08/11 Page: 3 of 6 PAGEID #: 13
JF THERE ARE ADDlTlONAL DEFENDANTS, PLEASE CONTINUE LISTING THEM.
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Case: 1:11-cv-00793-SAS-SKB Doc #: 3 Filed: 12/08/11 Page: 4 of 6 PAGEID #: 14
STATEMENT OF CLAIM
PLEASE WRITE AS BRIEFLY AS POSSIBLE THE FACTS OF YOUR CASE, DESCRIBE HOW EACH
DEFENDANT IS INVOLVED. INCLUDE THE NAME OF ALL PERSONS INVOLVED. GIVE DATES A]\.'D
PLACES.
DO NOT GIVE ANY LEGAL ARGUMENTS OR ClTE ANY CASES OR STATUTES,
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Case: 1:11-cv-00793-SAS-SKB Doc #: 3 Filed: 12/08/11 Page: 5 of 6 PAGEID #: 15
RELIEF
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SIGNED THIS _ ....._.-_. DA Y OF _::C'" .. ". - 20.
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SIGNATURE OF PLAINTIFF .
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Case: 1:11-cv-00793-SAS-SKB Doc #: 3 Filed: 12/08/11 Page: 6 of 6 PAGEID #: 16