Claim Suit Kohn, Brian, City Wt
AO 440 IR.. "91)1 S"mmo"' '"' C,"" A<'~"
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~niteb ~tates J§I istrirt (([ourt
DISTRICT OF
By'" í C\. V\ 0, J<OhV\
PIC\,; At-iff,
v.
SUMMONS IN A CIVIL ACTION
CASE NUMBER C ()'-{ -I ð¿;Z~ - LA R.
Git1 Of Dùbu«f€""¡ M;c.hft€-I Gd-y vV\C<I\'t')~í
V C( 1\ vv\; II i 8 e>" . Rd.~y Pe.vK fJ~r50V\"'e.Á M",,~ú'
R' . G . ' LJ",te..r ¡O¡",V\¡-rv'Yh(1~'~1'
ðb e..V+ re.e'v\¡ M,I<.e.. k3V"eK k ~ vJah~r 1C)¡",rt"\k.ùho"
Oe f' "- V\oltH-«s Sup-e.r oJj!-y)r
TO: "',....... ""'m 01 Dolo"",""
vi+y Of (J..)kJtX{)U~J City 1~4/1
¿SO 1:S 5í
Úùbv~U~ j:øu..Jq
YOU ARE HEREBY SUMMONED and required to file with the Clerk of this Court and serve upon
PLAINTIFF'S ATTORNEY '"O- O". ...,""
~ (' iClV\ (ù. k 0 c.V1
a<i3 \ rJ\V)~V'J ûÍ
VO cJ but \J Q:.. :row Cì C:;:J.{J() I
an answer to the complaint which is herewith served upon you, within ~1Ò days after service of
this summons upon you, exciusiv., of the day of service. If you fail to do so, judgment by default will be taken
against you for the relief aemandea in the complaint.
('~.
lo'
CLERK
PÂøQM I W:ltkins, ClerK
DATE
c¡ /;&/011
BY DEPUTY CLER;)
(/ ¿~vL
AO 399 112/93)
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WAIVER OF SERVICE OF SUMMONS
TO:
8fi'CvíA
KklloerT kð~~
(NAME OF PLAINTIFF'S ATTORNËY R UNREPRESENTEO PLAINTIFF)
I acknowledge receipt of your request that I waive service of a summons in the action of
Ci V /'1 At+~c 11\, , which is case number (' -O~ - IOu. - L4~
(CAPTION OF ACTION) (0 CKET NUMB R)
¡VO~'€.v"V\
,
-tOu Î~ , f:.,+~e..¡I'v\ f{);¡/I'si 0 V\ , I have also received a copy of the complaint in the
action, two copies of this instrument, and a means by which I can return the signed waiver to you without
cost to me,
in the United States District Court for the
District of
I agree to save the cost of service of a summons and an additional copy of the complaint in this
lawsuit by not requiring that I (or the entity on whose behalf I am acting) be served with judicial process
in the manner provided by Rule 4,
I (or the entity on whose behalf I am acting) will retain all defenses or objections to the lawsuit
or to the jurisdiction or venue of the court except for objections based on a defect in the summons or
in the service of the summons,
I understand that ajudgment may be entered against me (or the party on whose behalf I am acting)
if an answer or motion under Rule 12 is not served upon you within 60 days after C'J - J ~ - fJ';/. ,
(OATE REOU ST WAS ENT)
or within 90 days after that date if the request was sent outside the United States,
q "//;-" Dt{
DATE
SIGNATURE
PrintedlTyped Name:
As
of
(CORPORATE DEFENDANT)
(TITLE)
Duty to Avoid Unnecessary Costs at Service at Summons
Rule 4 of the Federal Rules of Civil Proced..e requires certain parties to cooperate in saving unnecessary costs at Bervice of the summons
and complaint. A defendant located in the United States who, after being notified of an action and asked by a plaintiff (ocated in the United States
to wBive service of a summons, fails to do so will be required to bear the cost of such service unless good cause be shown for its failure to sign
and return the waivBr.
It is not good cause for a failure to waive service that a party believBs that the complaint is unfounded, or that the action has been brought
in an imprope' place or in a court that (acks jurisdiction over the subject matter of the action o,ove, its person or property, A party who waives service
of the summons retains all defenses and objections (except any relating to the summons or to the service of the summons), and may later object
to the jurisdiction of the court 01 to the place where the action has been brought.
A defendant who waives service must within the timB specified on the waiver fonn serve on the plaintiff's Bttorney (or unrep,esented plaintiff)
a response to the complBint and must also me a signed copy of the response with the court. If the answer or motion Is not served within this time,
a default judgment may be taken against that detendant. By waiving service, a defendant is allowed more time to answer than if the summons had
been actually served when the request tor waiver of service was received.
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U,SIUAL EMPLOYMENT OPPORTUNITY COMlslON
DISMISSAL AND NOTICE OF RIGHTS
-------'--'-
Milwaukeo District
310 West Wisconsin Ave
Suite BOO
Milwaukee, WI 53203
2931 Pinard Street
Dubuque, IA 52001
relephooe No
Chester V, Bailey,
26A-2004-000B5 District Director (414) 297-1111
THE EEOC IS CLOSING ITS FILE ON THIS CHARGE FOR THE FOLLOWING REASON:
D
D
U
D
D
D
D
0
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0
Tns f"cts aliBged In the charge fa/I to state a claim under any of the 5tatute~.enforced by the EEOC.
'; O'lf ailegations d,d not ,n,olve a dtSahility as defined by the America"s with Disabilities Act.
Tne Respondent employs less Ihan fhe required number of employees or is nof ofhBrwise covered by the stalutes,
Your charge was not ¡¡mely filed with EEOC, 10 otherwo'ds, you wailed 100 long after the daters) of the alleged dlscrimlOatiQf1 to file your
cnarge.
Haviog been given 30 dnys ,n wh,Ch to respond, you fa.ied to provide infmmation, failed to appear or be availaDle for
,nlerviewsiconferences, or olhe~'ise failed to cooperate to Ihe extent thai It was not possible to resolve your chargB.
WhiiB reasonable Bfforts were madB to locate you, we were not able to do so
Y"" were ;',en 30 days 10 accept a reasonable seltlement offer that affords full reiief for the ha,m you alleged
The EEOC issues the following determin.Don, Based upon its investigation, the EEOC is unable to condude that the information oblained
establishes ,iolations of thB statutes. This does nol certify that the respondent IS in compliance with the statutes. No finding is made as
to any othBr issues thai migl1t be construed as having been ra,sad "y this charge.
"',e EEOC has adopted the ¡¡"dongs of the stale or loca! fai, Bmp!oyment pracirces agency that investigated this charge.
Other (b.oefly statel
- NOTICE OF SUIT RIGHTS -
(See Ihe additionat informalton attached to this form.)
Title VII, the Americans with DisJbilities Act, and/or the Age Discrimin,nion in Employment Act: This wili be the only
notice of dismissal and of to sue that we wili send you. You r"'ry file a lawsuit against the respondent(s) under
feojeral law based on federal or state court. Your ' lust be filed ~~,j)Q DI','rê of your ",ceipt
of this N()tic¡¡; based on this charge wili be lost. (Theîíme limit for filil1g suit based on a stale ciaim may
be different.)
Equal Pay Act (EPA): EPA suits must be filed in federal or state court within 2 years (3 years for wiltful violations) of the
a">'J~(i EPA underpayment. This means that back pay due for any violations that occurred mor~, th'!.!l;!,,~rs (3 vears)
hÒJr!> you file suit may not be collectible
EnG'csure(s)
c: ~ \!~" ~~"'=--,-
21JQ~
-~,_.,- . c .Ch..sterV:'Sàíìey,
District Director
(Date Maited)
City Of Du' 'ue
50 West 13HI Street
Dubuque, IA 52001
City Of Dl""", "
Attn: William G, Bium, City Blum
300 Main Street, #330
Dubuque, IA 52001-6944
,'A cëOC
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INFORMATION RELATED TO FILING SUIT
UNDER THE LAWS ENFORCED BY THE EEOC
, Ii lunilion refa',,',: Ie, (,'in; :,,:, Í!: I-, u,! 11 {I! Stale court ulI,!e" h,-lo(,!! ("I"".
If you plan to sue claiming vialaLiaÌls of State IiJw, please be awarethatlírrìiiTìiiiì{s"Ùnu other
provisions of State law may be shorter or more limited than those descnbed below.)
PRIVATE SUIT RIGHTS n Title VII of the Civil Rights Act, the Americans with Disabilities Act (ADA),
or the Age Discrimination in Employment Act (ADEA):
topuieUr' fuIU"',,'y',, dLlin;uitaga:nst reoi""'dclit(S)f!ClI"",i,,, ",il~il!
of the date you receive this Notice, The'efore, you should keep a record of this date. Once gO-dAY
over, your right to sue based cn the charge referred to in this Notice will be lost. If you intend to consull an
attorney, you should do so promptly. Give your attorney a copy of this Notice, and its envelope, and tell him or her Ihe
date you received it. Furthermore, in order to avoid any question that you did not act In a timely manner, it IS pruder,t
n-,a; 'iQur suit be filed within 90 days of the date this Notice was mailed to you (as indicated where the Notice is
s,ç,ned) or the date of the postmarK, if later
Your iaws~it may' ze"flled In tJ S. e""met Court or a State "n"t cn"'""!,,,,! i, ,,¡<"ic'inn r¡ Is, d':' "'0 ?nnnopriate
State court is the general civil trial court) Whether you file In Federal or State court is a matter for you to decide after
:0 attorney Filing this NoUce is not enough. You must file a "complaint" that contains a short statement
of your case which shows that you are entitled to relief, Your suit may include any matter alleged in the
charge or, to the extent permitted by court decisions, matters like or related to the matters alleged in the charge.
Generaliy, suits are brought in the State where the alleged unlawful practice occurred, but in some cases can be
brought where relevant employment records are kept, where the employment would have been, or where the
respondent has Its main office. If you have simple questions, you usually can get answers from the office of the clerk
of the court where you are bflnglng SUit, but dO not expect that office to wflte your cor,lplalnt or make legal strategy
decisions for you
PRIVATE SUIT RIGHTS -- Equal Pay Act (EPA):
EPA SUits must be filed in court within 2 years (3 years for willful violations) of the alleged EPA underpayment. back
poy dëc fc, .';oJ"t;cns that Dccërred mor" than 2 year. (3 vear.) before you file oc::t "'Sj not be coiiec1ible. For
example, If you were underpaid under the EPA for work performed from 7fl/00 to 12/1/00, you should file suit before
,C.LQ2 -- not 12/1102 -- in order to recover unpaid wages due for July 2000. This time limit for filing an EPA suit is
separate from the gO-day filing period under Title VII, the ADA or Ihe ADEA referred to above. Therefore, if you also
pian to sue under Title VII, the ADA or the ADEA, In addition to suing on the EPA claim, SUit must be filed within gO
cays of this Noke and within the 2- or 3-year EPA back pay recovery period
ATTORNEY REPRESENTATION -- Title VII and the ADA:
If you cannot afford or have been unable to obtain a lawyer to represent you, U,S. District Court havlnç¡ junsdlct'(I'
case in ':nces, assist you in ohtain¡'1g a ¡3"Fi f<eqddsts for such ass;,;t""c!.' "e
to ti,e 111 tt"" form and manner it requires (you should be prepared to explain in jour
efforts to retain an attorney) Requests should be made well before the end of the gO-day period mentioned above,
because such requests do not relieve you of the requirement to bring SUit within gO days
þ,'il ')',NEY REFERRAL AND EEOC ASSISH,NCE -- All Statutes:
You may contact Ihe EEOC representative shown on yûur Notice if you need he¡~ In finding, ,"'yer or If you have
any questions about your legal rights, including advice on which US, District Court can hear your case. If need
inspect or ",formation EEOC's file 01 ¡'ease reQuost It promptly in , ' ,vide
)'ourchargenu,r:¡', , ,,'mon your i,otlce). WhileEE:():~ chargefile53fteracertaintime, chi]', files
are kept for at least munchs aHer Our last action on the C3S:.. if you file suit and want to review the "iiarge
f!ie please make your review request ",ill:t.i!ULmonths of this Notice, (Before filing any request should be
the next 90 days.)
IF You fit ¡e SUIT, PLEA
SEND A COpy OF YOUR COURT COMPLAINT TO THIS OFFlc'/',
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CIVIL COVER SHEET e (1 ¿¡ fa ;",I){ <'
Th" JS ~ 44 c",1 cove; sheet and the 'nfoematlon contained he'Bin neither ..place nor supplement thB filing and service of plBadlngs or olhe; papers as reqwred
by law, e,cept as provided by local rules of cou,t This form, approved by the Jud<:lal Confe,ence of the United StBtes In Septembe' 1974, .. ,equired for the use
of the Cieri< of Court for the purpose of initlBtlng the civil docket sheet (SEE INSTRUCTIONS ON THE REVERSE OF THE FORM)
JS 44
(Rev 3199,
I. (a) PLAINTIFFS
Kû/1(\ ¿grift¡? 10
.
(b) "'CUNTYOCR"'OENCEOF"RSTU,STEDPLA>NHFF OUbúä.ue..
(EXCEPT IN US PLAINTIFF CASES) 11
(e) "')PNE"S ,"AM NAME ADaRESs AND TELEPHONE NUMeEAI
/J/4
DEFENDANW.
Crr.¡ ",,"' K7ùb'1>~, ¥t.V\ ¡IjI}.il" e~ Cd,!
íI1t""()t>r, Pec..k ~~ 4rs(J>1I\ftl ~"'%-"'~
~e"') Robc'" ,~<.:r"'" Ph/If ~5">:í. ß('t?kk
lnt~ið>Es~IJì,,~;Qh~ ~u ")ufJ"r"VI"'jðl'
NOTE
'N LAND CONOE~~A~;" ~~~~:T~~~~~ T~~~:) THE Dh, ",pi?
TRACT OF LAND INVOLVED
ATTORNEYS [I~ KN~WN' c.." t<t d{ r9"vt:U~ ~
A/t.u (,{},\t.c..tYI G, i'31;';>'~ ~It-y f?¡Jil1
600VV1<-i.i.v j-f1?ef P:3(I:J
II. BASIS OF JURISDICTION
0 T us Government
Plamtiff
02 US Go\r€rnment
D€tendanl
IV,
03 Fede'alOuestion
(US Government Not a Party)
IS.' Diversity
(IndICate Citlzensh,p of Parties
in Item III)
CONTRACT
NATURE OF SUIT (PLACE AN "X' IN ONE BOX ONLY)
TORTS
0110-
0 '20 Mð"~
0 ". ..,,~ AcT
0 ,.. """",.b..'n","~n'
0 ISO R"o,,~ " O"'p"mpo,
& 'olo"..oe",oIJ"'9""'",
0151-"""""
0 152 R.,"""'Y 0' a."~I""
S"-'L~,
1E>""""o""
0 153 R~~enro""'..p",m~'
"""'~"n,Be""""
0 ,.. 5<0""""".,, S~"
..,..""""",~~,
0 '05 Cem"", "'°"",, """"'0
REAL PROPERTY
0 ". """ CQ""~"e"
0 22<! """°,""
0 '3Ø R,c"'~e& E,.,,_c,
0:MO '0""0 "",'
0 ,as r""_",,"""'h~
0 29Ø AH "",", Real p"""",,,
V. ORIGIN
0 , Orig,na(
Proceeding
PERSONAL INJURY
0310 Ayp""e
0 3IS ~'p"oo P;oo""
""M~
0 32. """II, "bol &
Sl,,",,~
" 330 ~:::;~ Emp>o,."
0 3aØ Manco
0 34S M,,""o Pmd"",
",,',,',~
0 3SO MaIO"","""
0 3S5 MoW """"'0
Prado" ""~I,,y
0 300 "",", Pe~".'lcl"'V
CIVil RIGHTS
0441 ""'m9
1& 44' Emp"ymom
0 443 ",,""CO
Ae'om~d,,"oo'
0 - We",,~
0 ... "",", C"" R.on"
PERSONAL INJURY
0 "'" """°001 'C,"nr
Mod M,,'o',,""o
0 ... Pe~"", 'clory --
Pm'"" ".b>h'y
0 3ð8 A"""",,, Pe~n"
'~ory Prøduot L","iI"
PERSONAL PROPERTY
0 370 "'"~ ",,",
0 371 "omm "cd'""
0 300 ?H'~ "",~oc.,
0 ,.. o,'pen, a"m.;;
0"","" """""y
0 510 Mo"oc, "V"""
S""",
HABEAS CORPUS.
0 530 Ge,,~"
0 53S D"1h """,,,,
0 ... Macd.m", & "'"~
.... C"', R"Ot,
0 ... p"OO" Cocd",oc
Citizen of This State
PTF DEF
la' I !.'
Citizen of Anofher State 02 02
Citizen 01 Subject at a 0 J 0 3
Foreign Caunt,y
Foreign NBtlon
IncarporBted and P,inclpal Place 05 0'
of Business In Another StBte
06 06
FORFEITURE/PENALTY
BANKRUPTCY
"'10 ~~:' 'abo, S"""'~d, g ~ ~::c:.' ~~~'r9231
( no COOo,.Mgm' R"""oc, 0 863 aIWC¡OIWW ,,"51'"
PRISONER PETITIONS 0'" sseo ¡,He'~
0 730 ',"o"MOm' R.pomo, 0'" AS' ""'5Ig/l
& a,~lo'o" A"
0 74O R",w"y Labo' Ad
0 '10 A,"'"II""
0 020 "'"," '00. & 0,",
0 025 0"", R",,"d 5..,""
elo,oo,""," USCBS'
0 03Ø "O"or '.ow'
0'" RR &T~,,"
0 850 A"'me AoO'
1\ "'" ~I~':;'!~~~~
0 ... O"e,
0 m ADpe,,' 28 USC 158
0 423 W""d'~,,'
2" use '57
PROPERTY RIGHTS
0 820 CoPy"O'"
0 03Ø P""'o'
0 ... ¡"'dom""
LABOR
SOCIAL SECURITY
FEDERAL TAX SUITS
0 790 "',.. Labo' "'9""Oc
0070 r"",U5 01."",6
" D.le"""n!)
0 87' eRg -. ,"", Pan,
26 use ""
0 791 Emo' A.. In'
S"""'yA"
0 , Removed from
State Court
(PLACE AN "X",N ONE BOX ONLY)
rlansfelfed fcom
03 Remanded from ..' Reinstated or 0 s another d..(rict
Appellate Court Reopened (specify)
06 Multld.."ict
litigation
VI. CAUSE OF ACTION (mETHEU'; CMLSWUTE UNDER WHICH YOU ARE FILING AND wpnE BAIEF 5TATEMENTOF CAUSE
OONO¡,CITEJUAISD'C,TlONALSTATUTE5uNLfssaIVEASITYI , ,/I", '...1
1I1e. ð""'-(..-'(;A...." W',-U.. P"i>l~IO~htí"'" \.~T ~vy))(jf" #toe ffl\S r;J:C'?(;('I""',,~"tl.v
Ac..:t / t:.t.:..<, \ fLy kt I
DEMAND $
VII. REQUESTED IN
COMPLAINT:
CHECK IF THIS IS A CLASS ACTION
0 UNDERf'RC.P 23
OTHER STATUTES
0 400 5""0 Ae"ppon,om'lli"
0 4'. A"""""
0 ". B"n', ac' B.",,"'I
0 '5O çommeroo,'CC R..."""
0 ... 08p0"."""
047OR""......._-
CO"",,I-
0 810 "'eel". 5.~,oo
0 8SO S"""'""CommOd,""
E"',no'
0 875 co,"o~, """"nO"
/21iSC 3'"
088' ....."-"""",
0 ... Eco""""" SIat>rlu~o;; Aa
0 893 E~"onmenta' ...-
0 ... E""oY A"""."", A"
0 80S F'"""",,,or
'"""""""nAco
0 goo .""... oIF.. """"""""",,
U",..E...._,,-
0 9SO CM_",- 01
51.,.5"'0'"
0 ..., °",, S"'MOnr ""',""'
AppBaiiO Dlstnct
Judge trom
0 7 Magistrate
Judgment
ì f) ~~~
CHECK YES only if demanded In complaint
JURY DEMAND: 0 YES 0 NO
VIII.RELATED CASE(S) (SBB instruclions)
IF ANY JUaGE
";;E- 5 - 0 ~ a;N:: :rfw. Alj
-----..-,--.,....
DOCKET NUMBEA
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0600015t
1U5cll..J
INSTRUCTIONS
You should use this packet if:
(1) You are a prisoner, and
(2) You believe your federal constitutional rights have been violated, and
(3) You wish to file a complaint under 42 V.S.C. 5 1983 in the United
States District Court for the Northern District of Iowa, and
(4) You do not have a licensed attorney to help you with your complaint.
This
(1)
(2)
(3)
packet contains:
This 2-page sheet of INSTRUCTIONS (pages 1 and 2)
Form A (5 1983 complaint form) (pages 3-7)
Form B (request to proceed in forma pauperis and
and 9)
declaration) (pages 8
5 1983 or Habeas Corpus?
Sometimes prisoners do not know whether they should file a 5 1983 action or a
habeas corpus action. Both 5 1983 and the writ of habeas corpus can help
persons who have been deprived of federal constitutional rights. However, if
you will be asking the Court for any kind of release from custody, or if you
will be asking the Court to res~re good and honor time that was taken from
you, you should file a habeas corpus action. (The Court cannot do those
things for you in a S 1983 action.) In a habeas corpus action, you must ask
the state courts to help you before you ask for the federal court's help.
This is not required for a S 1983 action.
DO NOT USE THE FORMS IN THIS PACKET TO APPLY FOR A WRIT OF HABEAS CORPUS. A
separate form is available for that purpose. The Clerk of Court can send you
a copy upon request.
The Riaht Court and the Riaht Defendants
Your complaint can be filed in the United States District Court for the
Northern District of Iowa only if one or more of the defendants is located in
this district, or if the facts of your complaint took place in this district.
A defendant in a S 1983 action must be a person who
state law. This generally means that the person is
a state employee, or someone else who acted for the
given to him by the state. (This is not a complete
this subject, but is intended only as guidance.)
In order for the warden or some other supervisory official to be a proper
defendant, you must have some proof that such person either: (1) personally
did some act that harmed you, or (2) harmed you by personally failing to do
something he should have done, or (3) authorized (in words or otherwise)
someone else's conduct which harmed you, or (4) was aware of someone else's
conduct which harmed you, and acquiesced in (went along with) that conduct in
some way.
acted .under color of.
either a state official,
state or under some power
statement of the law on
It is important thàt you give the correct name and work address, if known, of
each person you name as a defendant, so that each of those persons can be
notified of your complaint.
1
.
.
Fillinq Out the Forms
Your forms may be filled out by hand or by typewriter. If handwriting is
used, it must be clear and readable. If printing would be easier for the
Court to read, please print. Every question on the forms should be answèred,
even if your answer is "none," "don't know," or "N/A" (not applicable).
Your complaint will be most effective if you (1) state your claim briefly
and plainly, and (2) tell the Court onlv about the claim or claims you truly
believe to be important. Stick to the FACTS (who, what, where, when, how).
THE COMPLAINT SHOULD NOT CONTAIN LEGAL ARGUMENTS OR CASE CITATIONS.
If you need more space to answer a question, you may use the back side of the
form or an extra blank page. However, if you keep your answers brief and to
the point, as recommended above, extra space should ~ be needed in most
cases.
You, the plaintiff must personally sign the complaint, and if there is more
than one plaintiff, each of you must sign. If a person other than a named
plaintiff helped you with your complaint, that person must sign in the place
indicated under Part VII.
Additional Claim~
If, in addition to your S 1983 claim, you have other claims against one or
more of the defendants, you may state those claims on a separate sheet of
paper which you attach to the complaint form. Write the heading ADDITIONAL
CLAIMS at the top of the sheet. If you happen to know the name or number of
a statute that you think applies to your additional claim, you may state it.
It is not necessarv, however, that you do so. If you just Btate the facts,
the Court will determine what federal or state laws, if any, apply. The
Court will also determine whether any state law claims can be decided in
federal court. Do J:!Q:r include any habeas corpus claims with this complaint.
Those claims should be filed separately on a special habeas corpus form which
the Clerk of Court can send you.
JJ /!i O. C\J Other!lBittructions
There is a fee of ~129.99 for filing your complaint. You will also be
required to pay the cost of notifyinv each defendant on your complaint. In
prisoner cases. this is usually done by certified mail, which costs
relatively little. If you feel vou cannot Dav the full filina fee and
service costs for this action, you should fill out Form B: REQUEST TO
PROCEED IN FORMA PAUPERIS AND DECLARATION IN SUPPORT THEREOF. If there is
more than one plaintiff, each olaintiff must comDlete a seoarate Form B. The
completed formes} should be Bigned and returned to the Clerk of Court with
your Form A complaint.
JJ ISO, O()
Mail your Form A complaint to the address below. With your complaint you
must send either a money order for elZe.ee ~ completed and signed Form B.
When all forms have been received, the Clerk will assign them to a judge.
Mailing address:
Clerk of Court
Federal Bldg. &U.S. Courthouse
101-lst Street S.E., Room 313
Cedar Rapids, IA 52401
NOTE: YOUR COMPLAINT WILL NOT BE CONSIDERED BY THE COURT UNLESS YOU HAVE
FOLLOWED THESE INSTRUCTIONS AND THOSE ON THE FORMS THEMSELVES.
.
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FORM A
FORM TO BE USED BY A PRISONER IN FILING A COMPLAINT
UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. S 1983
IN THE UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF IOWA
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,AY 0 5 2004
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(Enter above the full name of the
plaintiff or plaintiffs in this
action, )
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COMPLAINT
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(NOTE I If there is more than one plaintiff, a separate sh_t should be
attached qivinq the information in parts I and II below for ~ plaintiff,
by name.)
I.
Previous Lawsuits
A.
Have you bequn other lawsuits in state or federal court dealinq
with the same facts involved in this action or otherwise relatinq
to your imprisonment? YES () NO ( V )
If your answer to A is YES, please llnII-r the questions below.
(If there is more than one lawsuit, describe the additional
lawsuits on 'another piece of paper, usinq the same outline.)
8.
1.
Parties to previous lawsuit
Plaintiffs
.
.
Defendants
2.
Court (if federal court, name the district; if state court,
3,
name the county)
Docket Number
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,
4,
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Name of judge to whom case was assigned
5,
DiBposition, if known (for example: Was the case dismissed?
Was it appealed? Is it still pending?)
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6.
7.
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Approximate date of filing lawsuit
Approximate date of disposition
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II.
Place of Present Confinement
C,
D.
E.
Is there a prisoner grievance procedure in this institution?
YES (N NO ( )
Did you present the facts relating to your complaint in the state
prisoner grievance procedure? YES ()ZJ NO ( )
If your answer is YES,
A,
B.
2.
1.
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What steps did you take?
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What was the result?
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If your answer is NO, explain why not
If there is no prisoner grievance procedure in the institution,
did you complain to prison authorities? YES () NO (
4
.
.
F.
If your answer is YES,
1.
What steps did you take?
2.
What was the result?
I"
III.
Parties
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
plaintiffs, if any.)
A.
Name of Plaintiff
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AddresB
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B.
Additional Plaintiffs
IV.
In item C below, place the full name of the defendant in the first
blank, his official poBition 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.)
Defendant c,~~ oJ¿ KJd<\i')(~~ ~ N'\"'~L-.1Jv< }:s ~PlOyed as
I/Y\k",w::.er } ")!/(v{l/;<:,()r at (?;¡+v¡ ,Tc VJùbt)~Ur<>"
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Additional Defendant(s) are/is employed as
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This complaint is brought pursuant to 42 U,S.C. S 1983, and ~ t
jurisdiction is based on 28 U.S.C. S 1343(a)(3). Plaintiff(s)
C.
D.
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.
.
alleqe(s) that the defendant(s) acted under color of state law with
regard to the facts state in Part Vof this complaint.
V.
State of Claim
(State here as briefly as possible 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 Bheet if necesBarv, and write the heading
PART V CONTnroBD at the top of the sheet. Keep to the facts. Do not
give any 1sqa1 arguments or cite any cases.)
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VI.
Relief
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(State briefly exactly what you want the Court to do for You.
legal arguments. Cite no cases or statutes.)
Hake no
.
.
VII.
Statement Regarding AssiBtance in Preparing This Complaint
A.
Did any person other than a named plaint~ff in this action assist
you in preparing this complaint? YES ( \ ) No ( )
B.
If your Answer is YES, name the person who assisted. you.
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C.
VIII.
Signature of person whq'" helped Pf8P~/ complaint.
'7(~<L~e1 'I < < ! I" «~/é (Si~ture)
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Signatures of additional Plaintiffs, if any.
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IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF IOWA
DIVISION
~EOAR RAPiDS W"" -
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052004
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Plaintiff,
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Case
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APPLICATION TO
PROCEED IN FORMA
PAUPERIS in Civil
Rights Action
Defendants,
I, , declare that I am the
plaintiff in the above-entitled proceeding; that, in support of
my request to proceed without being requ~ed to prepay the full
$150,00 filing fee, I state that because of my poverty, I am
unable to prepay the filing fee for this action; that I believe I
am entitled to relief.
In further support of this application, I answer the
following questions:
1, Where are you imprisoned?
2,
When did you begin your imprisonment there?
3,
When do you expect to be released?
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4. Are you presently receiving an allowance or wages from the
prison or jail?,'¡' If the answer is XES, state the
amount of your allowance or wages per month. "
FO~M B
II.
.
.
Defendants
2.
Court (if federal court, name the district; if state court,
3.
4.
name the county)
Docket Number
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Name of judge to whom case was assigned
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5,
Disposition, if known (for exaMple: Was the case dismissed?
Was it appealed? Is it still pending?)
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6.
7,
Approximate date of filing lawsuit
Approximate date of disposition
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Place of Present Confinement
C.
D.
E.
A,
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Is there a prisoner grievance procedure in this institution?
YES (N NO ( )
Did you present the facts relating to lOur complaint in the state
prisoner grievance procedure? YES ( ~,,) NO ( )
If your ans_r is YES,
B.
2,
1.
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What stepB did you take?
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What waB the result?
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I f your ans-r is NO, explain why not
If there is no prisoner grievance procedure in the institution,
did you complain to prison authorities? YES () NO (
.
.
5. Have you received within the past 12 months any money from a
business, profession or other type of self-employment, or in the
form of rent payments, interest, dividends, retirement or
annuity, gifts, inheritances, court award or settlement, or other
sources? If YES, give the amount received and
identify the sources:
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6.
What is the current balance in your prison account?
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7 , Do you own cash, or do you have money in a che.cking or
savings account, other than a prison account? -\. i(1 If YES,
state the current balance: ~I~
8, Do you own any real estate, stocks, bonds, notes, vehicles,
or other valuable property (you need not mention ordinary
household and cell furnishings, such as, r..~iios, TV sets, stereo,
books, etc., and personal clothing)? rl.. , I:' If YES, describe
the property and state its approximate value:
I hereby authorize officials of the institution where I am
incarcerated to release my financial records to the court. My
identification number at this institution is !~i/!
I further authorize the agency holding me in custody to disburse
funds in an amount not to exceed $150,00 from my inmate account
to the Clerk of the United States District Court, Northern
District of Iowa, ,for the purpose of paying the initial partial
filing fee and subsequent installment payments in this case, I
declare under penalty of perjury that I have read the foregoing
and it is true, complete, and correct,
Signed this
day of
,19_.
(Signature of Plaintiff)
2
.
.
CERTIFICATE of INMATE ACCOUNT and ASSETS
I certify that the applicant,
1. D, # l / i\ ,has the sum of $
his/her credit at the ,I i, I
institution where he/she is confined. I further certify that the
applicant likewise has the following securities to his/her credit
according to the records of said institution:
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on account to
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I further certify that, during the last six months, the
applicant's average inmate account balance was $ , and
the past 6-month average monthly deposit amount to the inmate
account is $ /l.l i ! ,
Based on the above inmate account balance: (Check the
appropriate response)
Æ/ /i The applicant has sufficient funds in his/her acCOunt
to pay the $150.00 filing fee; OR
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The applicant has insufficient funds to pay the $150.00
filing fee in full at this time. I calculate that 20
percent of the greater of-
(a) the average monthly deposits to his/her prison
account; or
(b) the average monthly balance in his/her prison
accOunt for the 6-month period immediately
preceding the filing of the action
is $ I~,/t, for the purpose of an initial partial
filing fee, After payment of the initial partial
filing fee, this office will forward 20 percent of the
applicant's previous month's income as monthly payments
from his/her prison acCOunt to the clerk of the court
each time the amount in the acCOunt exceeds $10,00,
until the $150.00 filing fee is paid in full.
Signed this ------ day of
,19_,
Authorized Officer of Institution
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Rev 0599
(AN
ORIGINAL
RECEIPT FOR PAYMENT
UNITED STATES DISTRICT COURT
122511
RECEIVED FROM
lor the
NORTHERN DISTRICT ,:,,-PWA ,. "')
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E.YlliI;
6855XX-D08IANX
Deposrt Fund
6O4700-D08IANX
Re¡¡islry Fund
Geoeral & Soecial Fund~,
085000 Arty Adm Fees
086900 Filing Fees
0869PL Prisoner IFP F.Fees
109900 CnmínBl Debt Penalty I
Costs of Prosecution
322350 Copy Fees
322360 Miscellaneous Fees
504100 Crime Victims Fund
510000 Filing Fees Spec Aœt
5100PL Prisoner IFP Filing Fee
510100 Registry Fee Assessed
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Ched<s and d,,1ts a<. aec..p"", Subject '0 collection
and tull ,,"'," wUl on~ be given whe" the check '"
drait has be", accep'ed by the hnnndal institutioo
on which" was drawn
_DAiÈ-~"3 ./' -J:" -"/-- Cash c;hkk M.O, Croon DEPUTY.CURK.'__,(...-,.--, ^
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IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DI&'TRICT OF lOW A
EASTERN DMSION
BRIAN DELBERT KOHN,
Plaintiff,
No, C04-1O22-LRR
vs,
CITY OF DUBUQUE, MICHAEL V AN
*ULL~N,RANDYPECK,ROBERT
GREEN, MIKE BREKKE,
ORDER
Defendants.
This matter is before the court on the plaintiffs application to proceed in forma
pauperis. The plai~ submitted such application on May 5, 2004,
The plaimiffdili not sign his application to proceed in forma pauperis, See Fed. R,
Civ, P. 11 (regarding signing of pleadings); L.R. I I.1 (same), In addition, along with his
:,¡,pplication to proceed in forma pauperis, the plaintiff submitted a complaint and the
required $150.00 tiling fee, Because he did not sign his application to proceed in forma
pauperis and submitted the required $150,00 filing fee, the plaintiff's application to
proceed in forma pauperis is denied,
-~
IT IS SO ORDERED,
DATED this 2nd day of June, 2004,
A copy of this document has been
mailed/faxed to all counsel of record, pro
se parties and others listed and not shown
as having been served electronically
under rhe cmlecfsyorem:
612104-m¡
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UN A R. REA E
JU E, U. S, DISTRICT COURT
NORTHERN DISTRICT OF IOWA
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Orders on Motions
2:04-cv-Ol 022-LRR Kohn v, Dubuquc IA Citv of ct aJ
"np"'/eClnmU.m<^.lIclVcy,-nllltl "'I""ell 1" ".'." ",' "'It' "" 'i,"
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U.S. District Court
Northern District of Iowa
Notice ofEJectronic Filing
The foJlowing transaction was received from mj, entered on 6/2/2004 at 2:49 PM CDT and tiled on
612/2004
Case Name:
Case Number:
Filer:
Document Nü<1'ber:¿
Kohn v, Dubuque IA City ofet al
2:04-cv-lO22
Docket Tcxt:
ORDER: re [2JP.tiffs Motion for Leave to Proceed in forma pauperis is DENIED because he did not
sign his applicati~1FP and submitted the required $150 filing fee, Signed by Judge Linda R Reade on
6/2!()4, (mj)
The folJowing document(s) are associated with this transaction:
Document description:MainDocument
Original filenamc:nIa
Electronic document Stamp;
[STAMP dcecfStamp _10=] 025896836 [Date=6/2/2004] [FileNumber= 116813-0J
[4854()ld904f1 fe 7 f14b7a579cbß51 e5actb9638e3094 I 0004ced43abbc39824 I 0923
f1Je881413a9tb8dtb5d92ac5e30607a07bc93938229a 16cb8b5571 be3 36]]
2:04-cv-lO22 Notice will be electronically mailed to:
2:04-cv-1(122 Notice will not bc electronically mailed to:
~
2931 Pinard St
Dubuque, IA 52001
j
CLERK, U,S, DISTRICT COURT
P,O,BOX747fO
CEDAR RAPIDS, IOWA 52407-471 0
OFFICIAL aUSINESS
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ß~i2.n Delbert Kahn
2931 Pinard St
Dubuque, IA 52001
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IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF lOW A
EASTERN DIVISION
BRIAN DELBERT KOHN,
Plaintiff,
No. C04- !O22-LRR
VS,
CITY OF DUBUQUE, MICHAEL V AN
MILLIGEN, RANDY PECK, ROBERT
GREEN, MIKE BREKKE,
ORDER
Defendants,
This matter is before the court on the plaintiffs complaint, filed May 5, 2004. The
plaintiff failed to timely serve the summons and complaint upon the defendants. See Fed,
R. Civ, P. 4(m). If the plaintiff fails to serve the defendants by September 16, 2004, the
Clerk of Court is directed to dismiss with prejudice the plaintiff's complaint for failing to
respond to an order of this court and for tàiling to timely prosecute, See Fed. R. Civ, P.
41(b); Edgington v. Missouri Dept, of Corrections, 52 F.3d 777,779-80 (8th Cir. 1995);
Aziz v, Wright, 34 F,3d 587, 589 (8th Cir. 1994); Omaha Indian Tribe v, Tract 1 -
Blackbird Bend Area, 933 F.2d 1462, 1468 (8th Cir. 1991). Cf. L.R. 41.I(b),
IT IS SO ORDERED.
DATED this 9'10 day of September, 2004.
~~
JU GE, U. S. DISTRICT COURT
NORTHERN DISTRICT OF lOW A
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Other Orders/Judgments
~SH-cv-O¡ 022-I.RR Kohn v, Dubuilll"JA (:itv of et.J!l
U.S. District Court
Northern District oflowa
Notice of Electronic Filing
The following transaction was received from gcla. entered on 9/9/2004 at 3:48 PM CDT and tiled on
919/2004
Case Name:
Case Number:
Filer:
Document Number:-:!
Kohn v. Dubuque IA City of et al
:2 : 04:fy:LQ.:21.
Docket Text:
ORDER: the plaintifffailed to timely serve the summons and complaint upon defendants; case will be
dismissed if plaintiff tàils to serve defendants by 9/16/04; Dismissal Deadline 9/16/2004. Signed by
Judge Linda R Reade on 9/9/04. (Copy to Plaintit1) (gcla)
The following document(s) are associated with this transaction:
Document description: Main Document
Original filename:n/a
Electronic document Stamp:
[STAMP dcecŒtamp_ID=1025896836 [Date=9/9/2004] [FileNumber=147594-0]
[7054738a90258753b2bbJ c60cecl b53] bab9dedOdfOe3bbOOad93ff45b4a28e ] 597fc
37cbae662fOadf6809acdf4 7ca4998bb9a6 I 9b6b ] 308db83da4eOf5662d]]
2:04-cv-lO22 Notice will be electronically mailed to:
2:04-cv-1O22 Notice will not be electronically mailed to:
Brian Delbert Kohn
293] Pinard St
Dubuque.]A 52001
Brian Delbert Kahn
1931 Pinard St
Dubuque. JA 5200 I
.
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