Fill and Sign the Assault Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) COMPLAINT COMES NOW, the plaintiff, _______________, and files this her Complaint against the defendant, _______________, and in support thereof would show unto this Honorable Court the following facts, to-wit: FIRST CAUSE OF ACTION 1. The parties to this action are as follows: (a) The Plaintiff, _______________, is an adult resident citizen of _______________ County, _______________. (b) The Defendant, _______________, is an adult resident citizen of _______________ County, _______________ who may be served at his place of residence in the _______________, _______________ or at his place of employment which is _______________, _______________. 2. That on or about the _____ day of ____________, 20___, the Plaintiff was a social guest in the home of the Defendant. 3. That as a direct and proximate result of the negligence of the Defendant, the - 2 - Plaintiff sustained various injuries, including, but not limited to a broken hand.4. That as a direct and proximate result of _______________________________, Plaintiff sustained damages in an amount not less than $_______________. SECOND CAUSE OF ACTION 5. The Plaintiff incorporates the preceding paragraphs of this Complaint and makes them a part of this Cause of Action as if set forth in exact words and figures herein. 6. That for reasons unknown to the Plaintiff, the Defendant became enraged and physically assaulted the Plaintiff. 7. That said assault was intentional, willful, malicious and without any provocation whatsoever on the part of the Plaintiff. 8. That said assault entitles the Plaintiff to recover punitive damages in the amount within the jurisdictional limits of this court. WHEREFORE, PREMISES CONSIDERED, the Plaintiff prays that she recovers judgment of and from the Defendant in the amount of $_______________ actual damages and punitive damages in an amount not exceeding the jurisdictional limits of this Court. The Plaintiff prays for such other relief, general or specific, to which she may be entitled. Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: - 3 - 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____. ____________________________________