Fill and Sign the Comes Now and Plaintiffs and File This Their Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) COMPLAINT COMES NOW, ______________ and ______________, Plaintiffs, and file this their Complaint against ______________ and ______________, and would show unto the Court as follows, to-wit: 1. Plaintiffs ______________ and ______________, husband and wife, are adult resident citizens of ______________ County, ______________ whose address is __________________________________________. 2. ______________ is a ______________ Corporation qualified to do business in ______________, whose agent for service of process is ______________. 3. Defendant ______________ is an adult resident citizen of ______________ whose residence address is unknown to Plaintiffs, but who may be served with process of this Court at his place of employment at ______________. 4. Plaintiff would show that on or about the _____ day of ___________, 20____, he was an invitee of Defendant ______________, at its operation located at ______________, - 2 - ______________, where it was doing business as ______________ in ______________ County, ______________. Plaintiff would show that on that date, ______________ negligently operated a nail stud gun by firing the stud gun causing it to discharge a nail, causing the nail to strike the concrete causing particles of concrete and other material to strike the eye of ______________, causing him blindness in his left eye. 5. Plaintiff would show that at all times herein complained of, ______________ was the agent, servant and employee of ______________, who is liable for the actions of ______________, Plaintiffs would show that as a result of the negligent actions of ______________, Plaintiff's left eye was damaged resulting in permanent blindness. Plaintiff would show that the acts of ______________ were done in a grossly negligent manner manifesting reckless indifference for the health and safety of others including ______________, thereby entitling the Plaintiffs to an award of exemplary or punitive damages. 6. Plaintiff would show that as a result of his injuries he has suffered permanent blindness and disfigurement of the left eye and suffers from a combination of medical proble ms resulting therefrom. 7. Plaintiff would show that he has been required to seek medical treatment for his injuries and has incurred medical expenses and will incur medical expenses in the fut ure. Plaintiff would show that as a result of his injuries he is no longer able to continue t he same employment for which he is suited and has lost wages, suffered a loss of wage earning capaci ty and will suffer a loss of future wages. 8. Plaintiff would show that he has suffered pain and suffering in the past and will experience the same in the future. 9. Plaintiffs would show that ______________ and ______________ are husband - 3 - and wife and that she has suffered a loss of consortium as a result of the injuries of ______________.WHEREFORE, PREMISES CONSIDERED, Plaintiffs sue and demand judgment of and from Defendants, jointly and severally, in the amount of $______________ general damages plus $______________ punitive or exemplary damages plus attorneys fees plus interest on judgment from the date of the incident plus all costs of court. Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: - 4 - 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____. _________________________________