Fill and Sign the Ca Personal Injury Form

— DO NOT FILE WITH THE COURT — — UNLESS YOU ARE APPLYING FOR A DEFAULT JUDGMENT UNDER CODE OF CIVIL PROCEDURE § 585 — ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address) : TELEPHONE NO.: ––––– ––––– ––––– ––––– ––––– ATTORNEY FOR (Name) : ––––– FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF ––––– STREET ADDRESS: ––––– MAILING ADDRESS: ––––– CITY AND ZIP CODE: ––––– BRANCH NAME: ––––– PLAINTIFF: ––––– DEFENDANT: ––––– STATEMENT OF DAMAGES (Personal Injury or Wrongful Death) CASE NUMBER: ––––– To (name of one defendant only) : ––––– Plaintiff (name of one plaintiff only) : ––––– seeks damages in the above-entitled faction as follows: AMOUNT 1. General damages a. Pain suffering, and inconvenience $ 0.00 b. Emotional distress $ 0.00 c. Loss of consortium $ 0.00 d. Loss of society and compassion (wrongful death actions only) $ 0.00 e. Other (specify) : ––––– $ 0.00 f. Other (specify) : ––––– $ 0.00 g. Continued on Attachment 1.g. 2. Special damages a. Medical expenses (to date) $ 0.00 b. Future medical expenses (present value) $ 0.00 c. Loss of earnings (to date) $ 0.00 d. Loss of future earning capacity (present value) $ 0.00 e. Property damage ) $ 0.00 f. Funeral expenses (wrongful death actions only) $ 0.00 g. Future contributions (present value) (wrongful death actions only) $ 0.00 h. Value of personal service, advice, or training (wrongful death actions only) $ 0.00 i. Other (specify) ––––– $ 0.00 j. Other (specify) ––––– $ 0.00 k. Continued on Attachment 12.k. 3. Punitive damages: Plaintiff reserves the right to seek punitive damages in the amount of (specify) $ 0.00 when pursuing a judgment in the suit filed against you. Date: ––––– ––––– 4 (TYPE OR PRINT NAME) (SIGNATURE OF PLAINTIFF OR ATTORNEY FOR PLAINTIFF) (Proof of service on reverse) Form Adopted by Rule 982 Judicial Council of California CIV-050 [Rev. January 1, 2007] STATEMENT OF DAMAGES (Personal Injury or Wrongful Death) Code of Civil Procedure, §§ 425.11, 425.115 electronic form ã 1999 WWW.LawCA.com Law Publishers CIV-050 PLAINTIFF: ––––– ––––– DEFENDANT: ––––– CASE NUMBER: ––––– PROOF OF SERVICE (After having the other party served as described below, with any of the documents identified in item 1, have the person who served the documents complete this Proof of Service. Plaintiff cannot serve these papers. 1. I served the a. Statement of Damages Other (specify) : ––––– b. on (name) : ––––– c. by serving defendant other (name and title or relationship to person served) : ––––– d. by delivery at home at business (1) date: ––––– (2) time: ––––– (3) address: ––––– ––––– e. by mailing (1) date: ––––– (2) place: ––––– 2. Manner of service (check proper box) : a. Personal service. By personally delivering copies. (CCP 415.10) b. Substituted service on corporation, unincorporated association (including partnership), or public entity. By leaving, during usual office hours, copies in the office of the person served with the person who apparently was in charge and thereafter mailing (by first-class mail, postage prepaid) copies to the person served at the place where the copies were left. (CCP 415.20(a)) c. Substituted service on natural person, minor, conservatee, or candidate. By leaving copies at the dwelling house, usual place of abode, or usual place of business of the person served in the presence of a competent member of the household or a person apparently in charge of the office or place of business, at least 18 years of age, who was informed of the general nature of the papers, and thereafter mailing (by first-class mail, postage prepaid) copies to the person served at the place where the copies were left. (CCP 415.20(b)) (Attach separate declaration or affidavit stating acts relied on to establish reasonable diligence in first attempting personal service.) d. Mail and acknowledgment service. By mailing (by first-class mail or airmail, postage prepaid) copies to the person served, together with two copies of the form of notice and acknowledgment and a return envelope, postage prepaid, addressed to the sender. (CCP 415.30) (Attach completed acknowledgment of receipt.) e. Certified or registered mail service. By mailing to an address outside California (by first-class mail, postage prepaid, requiring a return receipt) copies to the person served. (CCP 415.40) (Attach signed return receipt or other evidence of actual delivery to the person served.) f. Other (specify code section) : ––––– additional page is attached. 3. At the time of service I was at least 18 years of age and not a party to this action. 4. Fee for service: $ ––––– 5. Person serving: ––––– a. California sheriff, marshal, or constable b. Registered California process server c. Employee or independent contractor of a registered California process server d. Not a registered California process server e. Exempt from registration under Bus. & Prof. Code 22350(b) f. Name, address and telephone number and, if applicable, county of registration and number: ––––– ––––– ––––– ––––– ––––– I declare under penalty of perjury under the laws of the State (For California sheriff, marshal, or constable use only) of California that the foregoing is true and correct. I certify that the foregoing is true and correct. Date: ––––– Date: ––––– 4 4 (SIGNATURE) (SIGNATURE) CIV-050 [Rev. January 1, 2007] PROOF OF SERVICE (Statement o Damages) Page two Code of Civil Procedure, §§ 425.11, 425.115 electronic form ã 1999 WWW.LawCA.com Law Publishers CIV-050