Fill and Sign the Auto Accident Passenger 497426719 Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT COMES NOW Plaintiff ________________________, by and through undersigned counsel, and states as follows: 1. Plaintiff is a resident citizen of the County of _____________, State of _____________, and is over the age of twenty-one (21) years. 2. Defendant is a resident citizen of the County of _______________, State of _____________, and is over the age of twenty-one (21) years. 3. On or about the _______ day of _______________, __________, Plaintiff was a passenger in a motor vehicle operated by Defendant, while Defendant was operating said vehicle upon a public highway, [name of road or street], in ____________ [name of City or County], _____________. 4. Set out specifics of accident and the wanton behavior of the driver of the passenger’s car that caused or contributed to the accident. - 1 - 5. As a proximate result of the Defendant’s willful and wanton misconduct in the operation of said vehicle, Plaintiff was caused to suffer the following injuries and damages: [enumerate injuries and damages here wages, out of pocket, exact physical injuries, bruises, contusions , sick, sore, and lame, mental anguish, stress etc.]. WHEREFORE, Plaintiff demands judgment against Defendant in excess of the jurisdiction limits of this court for compensatory and punitive damages, interest, and costs. PLAINTIFF RESPECTFULLY REQUESTS A TRIAL BY JURY AS TO ALL COUNTS HEREIN Respectfully submitted, Dated: Name:       Title:       Address:       Address:       City, State, Zip:       Phone:       Fax:       E-Mail:       Attorney No.:       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____. _________________________________ - 2 -