Travis Ball Lawsuit
Travis Ball Lawsuit
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IN THE UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF VIRGINIA
F JAN i 5 2020
Please fill out this complaint form completely. The Court needs the information requested in
order to assure that your complaint is processed as quickly as possible and that all your claims
are addressed. Please print/write legibly or type.
I. PARTIES
Pla^ff:
(a) froiU'S Adron Sctll (b)
dooHvn
(Name) (Inmate number)
(r)f-Q. ^)C/0(d0 MlcK
(Address)
Plaintiff MUST keep the Clerk of Court notified of any change of address due to transfer
or release. If plaintiff fails to keep the Clerk informed of such changes,this action may be
dismissed.
Plaintiff is advised that only persons acting under the color ofstate law are proper
defendants under Section 1983. The Commonwealth of Virginia is immune under the
Eleventh Amendment. Private parties such as attorneys and other inmates may not be
sued under Section 1983. In addition, liability under Section 1983 requires personal action
by the defendant that caused you harm. Normally,the Director of the Department of
Corrections, wardens,and sheriffs are not liable under Section 1983 when a claim against
them rests solely on the fact that they supervise persons who may have violated your rights.
In addition, prisons,jails, and departments within an institution are not persons under
Section 1983.
B. Defendant(s):
I. (a) (b)
(Name) (Title/Job Description)
(p) Mtck.
(Address)
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■ JAN 1^ 2020
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3. (g) f^OrSittn /{Put
(Name) (Title/Job Description)
(r) .f^fb4kv'nM^£ jlt^xJ>^/
(Address)
If there are additional defendants, please list them on a separate sheet of paper. Provide all
identifying information for each defendant named.
Plaintiff MUST provide a physical address for defendant(s)in order for the Court to serve
the complaint. If plaintiff does not provide a physical address for a defendant,that person
may be dismissed as a party to this action.
A. Have yoU ever begun other lawsuits in any st^ or federal court relating
to your imprisonment? Yes[ ] No [(/]
B. If your answer to "A" is Yes: You must describe any lawsuit, whether currently
pending or closed, in the space below. If there is more than one lawsuit, you
must describe each lawsuit on another sheet of paper, using the same outline,
and attach hereto.
Plaintiff(s)
Defendant(s)_
2. Court(if federal court, name the district; if state court, name the county):
4. Docket number:
Case 3:20-cv-00027-HEH-RCY Document 1 Filed 01/15/20 Page 3 of 8 PageID# 3
6. Disposition (Was case dismissed? Appealed? Is it still pending? What relief was
granted, if any?):
A. At what institution did the events concerning your current complaint take place:
/ 7^''/
B. Does the institution listed in "A" have a grievance procedure? Yes[k ] No[ ]
State here the facts of your case. Describe how each defendant is involved and how you were harmed
by their action. Also include the dates, places ofevents, and constitutional amendments you allege
were violated.
If you intend to allege several related claims, number and set forth each claim in a separate
paragraph. Attach additional sheets if necessary.
1^" MAyuJ, ^
V. RELIEF
I understand that in a Section 1983 action the Court cannot change my sentence, release me from
custody or restore good time. I understand I should file a petition for a writ of habeas corpus if I
desire this type ofrelief^A (please initial)
The pl^ntiff wants the Court to:(check those remedies you seek)
Award money damages in the amount of$ 1^
^Grant injunctive relief by /K <; X c<w ^
Other
Please list the institutions at which you were incarcerated during the last six months. If you were
transferred during this period, list the date(s) oftransfer. Provide an address for each institution.
VII. CONSENT
CONSENT TO TRIAL BY A MAGISTRATE JUDGE: The parties are advised oftheir right,
pursuant to 28 U.S.C. § 636(c), to have a U.S. Magistrate Judge preside over a trial, with appeal to
the U.S. Court bf Appeals for the Fourth Circuit.
Do you consent to proceed before a U.S. Magistrate Judge: Yes[ ] No[ ]. You may
consent at any time; however, an early consent is encouraged.
VIII. SIGNATURE
If there is more than one plaintiff, each plaintiff must sign for himself or herself.
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Case 3:20-cv-00027-HEH-RCY Document 1-1 Filed 01/15/20 Page 1 of 10 PageID# 9
Resolution Attempted Briefly explain what you have done to solve this problem before you resorted jo a grievance form
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Administrative Response
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Inmate Review
Name_ Time /
Date / ;
Housing
REQUEST:
Response:
Signature^ Date
Name Time
Date Housing.
REQUEST:
Action Taken:
Response:
Date
Signature_
Name_ Time
Date Housing
REQUEST:
Response: 4
Signature Date
Name_ Time
Date Housing,
REQUEST:
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Staff Receiving the Request: mi(a. Date_jJ£jjiO.
Supervisory Review: T Date
Action Taken:
Response:
Signature, Date
Name. ; Time
Date Housing.
REQUEST:
Response: \ C; . I O C
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Signature, Date I N
Naine_/ Time
Date Housing,
REQUEST:
Response:
Signature_ Date
Prescription $3.00
X-Ray $20.00
Over-Counter Medication $
Other:
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Name U\\ji
Date I Housing F- ry
REQUEST: /,r -V
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Staff Receiving the Request: ^ T. Date
Supervisory Review: Date
Action Taken:
Response:
Signature_ Date
REQUEST:
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Staff Receiving thb Re^eSst: i fe
Supervisory Review
Action Taken:
Response:
Sighature Date
Original -
Copy 1 -
Copy 2r Retainedi by Iimm of Requert,
Case 3:20-cv-00027-HEH-RCY Document 1-2 Filed 01/15/20 Page 1 of 1 PageID# 19
STATE OF VIRGINIA
CITY/COUNTY OF...^^.(S.^.
The petitioner being duly sworn,says:
Signature of Petitioner
thisA^day ,20.?>P..
Notary Public
My commission expires:
The chapters of the acts of assembly referenced in the historical citation at the end of this section
may not constitute a comprehensive list of such chapters and may exclude chapters whose
provisions have expired.
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