Fill and Sign the Complaint for Personal Injury and Wrongful Death Due to Shooting Violence Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) COMPLAINT The Plaintiffs, by and through their attorneys, file this their Complaint, and in support of their claims against the Defendant, would show unto the Court the following: 1. The names and addresses of the Plaintiffs, along with their relationship to the decedent are as follows: a) __________________________, Father, ____________________________ b) __________________________, Mother, ___________________________ c) __________________________, Sister, _____________________________ d) __________________________, Sister, _____________________________ e) __________________________, Sister, _____________________________ f) __________________________, Brother, ____________________________ g) __________________________, Sister, _____________________________ 2. The Defendant, _________________________, is an adult resident citizen of __________________ County, and may be served with process of this Court at the __________________________ County Jail. 3. The Plaintiffs' claims against the Defendant arose and accrued in _________________ County, _________________________. COUNT I. 4. On or about the ______ day of ____________, 20___, the Defendant wrongfully, intentionally, and/or negligently shot the decedent, __________________________, numerous times with a .44 magnum revolver. - 2 - 5. As a direct and proximate result of said wrongful action, the decedent, __________________________, died. 6. If the death of ______________________________ had not occurred, __________________________ would have been entitled to maintain an action and recover damages in respect of the wrongful actions of the Defendant. 7. The wrongful actions of the Defendant as described above proximately caused the death of __________________________, whose personal representatives are entitled to recover monetary damages from the Defendant. COUNT II. 8. The Plaintiffs incorporate by reference each and every averment made in the paragraphs above. 9. As a direct and proximate result of the wrongful actions of the Defendant as described above, the Plaintiffs have lost the consort, society, companionship, affection, incom e services, and support of __________________________ and have suffered mental anguish and emotional distress because of the injury and death of __________________________. 10. The wrongful actions of the Defendant as described above proximately caused the injuries suffered by the Plaintiffs who are entitled to recover monetary damages from the Defendant. COUNT III. 11. The Plaintiffs incorporate by reference each and every averment made in the paragraphs above. 12. The wrongful actions of the Defendant were willful and/or grossly negligent and were so wanton as to show a disregard for the safety of others, thus giving rise to an award of punitive damages against the Defendant. WHEREFORE, the Plaintiffs demand judgment of and from the Defendant in the sum of at least ___________________ Dollars ($00.00) actual damages and _________________ Dollars ($00.00) punitive damages, together with reasonable attorney's fees and all costs of Court herein. Respectfully submitted, - 3 - 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____. __________________