Affidavit of Inability to Pay Filing Fees and Other Costs

IN THE COURT OF COUNTY

STATE OF

COMPLAINT
(NEGLIGENCE-BUSINESS OWNER LIABILITY-SLIP & FALL)

COMES NOW the Plaintiff(s), , by counsel, and for his/her Complaint against the Defendant(s), , alleges and states:

I. THE PARTIES

1. The Plaintiff(s), (hereinafter referred to as Plaintiff), is an adult citizen of County, State of and resides at in the City of

2. The Defendant, (hereinafter referred to as Defendant One), is a corporation incorporated under the laws of the State of whose principal place of business is at in the City of and is subject to service of process by and through its registered agent:

II. THE FACTS

3. On the day of , 20, at approximately o'clock a.m., the Plaintiff was a business invitee at Defendant's grocery store. While shopping in the produce section of defendant's store, Plaintiff slipped and fell near the lettuce display in a clear liquid substance believed to be water standing on the all-white tile floor. Plaintiff was immobilized by the fall on the floor and other shoppers and the store's assistant manager came to Plaintiff's assistance. While on the floor, the water-misting system on the nearby lettuce display began operating and spraying water on the Plaintiff and the floor in area where she fell.

4. The Defendant had actual or constructive notice that the said water-misting system sprayed water on the floor creating a hazardous and dangerous condition.

a. The Defendant did not take any steps reasonably calculated to remove the aforesaid dangerous and hazardous condition.

b. The Defendant did not post any signs or other devices warning persons of the dangerous and hazardous condition.

III. THE CLAIMS

5. Defendant a duty to maintain its business premises in a reasonably safe condition, a duty to take steps reasonably calculated to remove the aforesaid hazardous and dangerous condition, and a duty to warn its business invitees of the aforesaid dangerous and hazardous condition.

6. The Defendant breached its duties delineated hereinabove proximately causing Plaintiff to suffer the following damages:

IV. DEMAND FOR RELIEF

7. The Plaintiff prays for the following relief:

(1) Trial by jury;

(2) Judgment for Plaintiff and against the Defendant;

(3) An award of damages which will fully and fairly compensate Plaintiff for

(4) Such other and further relief deemed just and proper in the premises.

CERTIFICATE OF SERVICE

I, , do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to at the following address;

THIS the day of , 20