Fill and Sign the Bill Personal Injury Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) BILL OF COSTS Judgment having been entered in the above-entitled action on the ____ day of ____________, 20____, against _______________ and _______________, the Clerk is requested to tax the following as costs: Fees for Copying Exhibits # Copies @ $ $ Other $ $ $ Fees for Witnesses Witness Name Witness Fee Mileage Fee Total $ $ $ TOTAL COSTS $ - 1 - DECLARATION I declare under penalty of perjury that the foregoing costs are correct and were necessarily incurred in this action. A copy of this bill was mailed today with postage prepaid to ________________________ at the following address: ________________________________. Costs are taxed and included in the amount of the judgment. ________________________ Clerk of Court By: _________________ Date: ______ day of _______________, 20____. CERTIFICATE OF SERVICE I, _______________________ , one of the attorneys of record for defendant, do hereby certify that I have this day mailed a true and correct copy of the above and foregoing BILL OF COSTS to _______________________ at the following address: ____________________________________ This the _____ day of _____________, 20____ _____________________________ - 2 -