Fill and Sign the Complaint Form Court

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) COMPLAINT COMES NOW _____________ and for cause of action against _____________ alleges as follows: I. Plaintiff _____________ is an adult resident citizen of _____________ County, _____________, and resides at _____________, _____________ County, _____________. II. Defendant is a _____________ Corporation and has as its registered agent for service of process _____________ who may be served with process at _____________. III. Plaintiff _____________ alleges that on or about ______________ she was exiting the _____________ on the _____ day of _____________, 20___. Said building is owned, occupied and managed by Defendant. As Plaintiff stepped down from the concrete steps in front of said building, she caught the heel of her shoe in a crack in the concrete, causing her to fall and sustain - 2 - serious, painful and permanent injuries as hereinafter described. Said crack was higher on one side than the other side, which was deceptive in appearance, and the uneven height contributed to the cause of Plaintiff's fall. IV. Plaintiff has suffered injuries and damages as a direct and proximate result of the negligence of Defendant as follows: a. _______________________________________ b. Negligent failure to warn individuals such as Plaintiff of the hazardous and dangerous condition which then and there existed, which was known or should have been known by defendant. c. Failure to maintain the steps in a reasonably safe condition; d. Failure to provide a handrail, e. Other acts of negligence to be shown at trial which may be learned through discovery. VI. Plaintiff _____________ alleges that as a result of the negligence of the Defendant, and the aforesaid accident, the Plaintiff sustained a severely fractured right ankle, and as a result thereof had to have surgery and a steel pin inserted. Medical bills thus far have exce eded $_______________. Plaintiff has had to endure grievous pain and suffering as a result of her injury, continues to suffer with her injury at this time, and reasonably believes that she will suffer permanently from her insures. In addition, Plaintiff reasonably believes that she will require medical treatment in the future for the treatment of said injuries. Plaintiff has suffered permanent disability as a result of her injuries, and will never enjoy the healt h she enjoyed prior - 3 - to the subject accident. All such damages are as a result of the negligence of Defendant.VII. Plaintiff alleges that the negligent acts of the Defendant were the proximate cause or the proximate contributing cause of the Plaintiff's accident and injuries. WHEREFORE, PREMISES CONSIDERED, Plaintiff sues and demands judgment of and from _____________ in the amount of $________________. 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____. _____________________________