Fill and Sign the Auto Accident Passenger Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT For cause of action against the Defendant, the Plaintiff alleges the following: I. Plaintiff, _______________, is a minor residing in _______________ County, _______________ and brings this suit by his mother and next friend, _______________. II. Defendant, _______________, is an adult resident citizen of _______________ County, _______________ and may be served with process of this Court by service on him at his place of residence which is _______________, _______________ or _______________, _______________in _______________ County. III. On or about the ____ day of _______________, 20____, the Plaintiff, _______________, was a passenger in the back seat of a _______________ owned by _______________ and driven by the defendant, _______________, with the permission of _______________, and it was involved in a collision with a bridge embankment due to the - 1 - negligence of _______________. IV. As a direct and proximate result of the negligence of _______________, the Plaintiff, _______________, sustained serious permanent and painful injuries to his body and other damage secondary thereto, including, but not limited to the following: 1. A broken neck; 2. Severe pain and suffering; 3. Medical expenses; 4. Inability to participate in sports of any kind, including gymnastics; 5. Physical therapy expenses; 6. Permanent disability; 7. Dental expenses; 8. Increased risk of degenerative changes to his broken neck above and below the fracture site; and 9. Psychological and emotional injuries. WHEREFORE, Plaintiff demands judgment against the Defendant _______________ in the sum of $_______________ compensatory damages, interest and cost of this action. Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: - 2 - 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____. _________________________________ - 3 -