SF95 SF95 Attachment 2. Name* First Middle Last Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 3. TYPE OF EMPLOYMENT* Civilian Military 4. Date of Birth* Month Day Year 5. Marital status* Single Married Divorced 1. FEDERAL AGENCY COMPLAINED OF*Select all that apply Dept. of Justice FBI Federal Marshal Service US Federal Public Defender Bureau of Prisons Capital Police DC Metro Police Other (Described below) Other Federal Agency8. BASIS OF CLAIM*My constitutional and civil rights were violated by the above Federal Agencies in the following ways: (Please check all that apply) Arrested SWAT ed Held at gunpoint Spouse and / or children and / or family held at gunpoint Handcuffed / Shackled Spouse and / or children and / or family handcuffed / shackled Property taken Property Not returned Please check all that apply Pre-trial Detention House arrest (Enter the amount of day below) Ankle Monitor (Enter the amount of days below) Placed on terrorist watchlist / Quad S Spouse and/or children also placed on terrorist watchlist / Quad S Travel restrictions Drug / alcohol tested Surveilled Charged with crimes I did not commit Provided biased Public Defender Had evidence fabricated, destroyed, withheld and / or altered Please check all that applyDays under house arrestDays with ankle monitor Plead Guilty Tried by a biased court Tried by a biased Jury Please check all that applyPlease check all that apply Sentenced to House Confinement (Enter days below) Sentenced to House Confinement with monitor (Enter days below) Sentenced to Probation (Enter months below) Incarcerated (Enter month below) Solitary Confinement (Enter days below) House Confinement with/without Monitor (Days)Incarcerated Pre-trial (Days)Probation (Months)Incarcerated Post sentence (Month)Kept in Solitary confinement (Days)9. PROPERTY DAMAGE*If you did not have any Property Damage please put (N/A) for Not Applicable 10. NATURE AND EXTENT OF PERSONAL INJURY*Please check all that apply Extreme permanent emotional and physical injury Beaten, gassed, assaulted on 1/6/2021 Incarcerated Beaten, assaulted while incarcerated or in custody Denied medical care in custody Solitary confinement Diesel Therapy moved from facility to facility Loss of earnings / earning capacity Loss of job Loss of business Loss of employability Loss of professional license / privileges / practice Loss of retirement benefits Debanked Credit damaged / destroyed Loss of home / real estate Doxed Intentional public humiliation upon arrest Threatened / harassed Forced to move / relocate Barred from Uber, Lyft, Airbnb, social media, etc Slandered / libeled by the media / websites / internet Forced to live under the constant weight of public disdain, scorn and hate Loss of reputation Loss of family relationships Divorce / loss of child custody Loss of social relationships Missed birth of children, deaths of family / friends Missed graduations / weddings Attorney fees, fines, court costs, travel expenses to court Psychological and physical illness due to stress / anxiety / physical and mental abuse Other (describe below) Other Injury12a. Total Property Damage*12b. Total Personal Injury*12d. Total Amount Claimed*Total Amount Claimed is Calculated by adding 12a and 12b, if the amount automatically populated below is not correct please adjust 12a and/or 12b to change.NameThis field is for validation purposes and should be left unchanged.
