Fill and Sign the Complaint Injury Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT COMES NOW _______________, Plaintiff, and in support of his claim for relief would show unto the Court the following facts, to - wit: 1. That _______________ is an actual adult resident citizen of _______________ County, _______________. 2. That the Defendant, _______________, is an actual adult resident citizen of _______________ County, _______________; that he is a security guard at _______________ at _______________, _______________, where he may be served with process. 3. This Court has jurisdiction of the parties and of the subject matter of this cause. 4. Plaintiff would show that on or about the _____ day of ______________, 20____ that he was at his home in _______________ County, _______________, when he was approached by the Defendant herein, _______________, and that _______________, after an argument with the Plaintiff, for no apparent reason, without justification, and in a grossly reckless, negligently and intentionally manner shot and injured the Plaintiff. That as a result of - 1 - the gunshot wound that the Plaintiff required medical attention, doctor bills, and hospitalization, that his bills continue to accrue, and that he has suffered severe mental anguish and anxiety, and that he has permanent disability as a result of this injury. 5. Plaintiff would show that Defendant owed him a duty and duties and that that these duties were breached, to - wit: a. That the Defendant committed an aggravated assault and battery on the Plaintiff herein. b. That the aggravated assault and battery was committed without justification in a grossly negligent, intentional, willful and reckless manner. 6. As a proximate result of these breaches of duty, Plaintiff has sustained special damages in a sum of no less than $_______________, and that he is entitled to punitive damages in a sum of $_______________. WHEREFORE, PREMISES CONSIDERED, Plaintiff files this suit and demands judgment of and from the Defendant for both actual or compensatory damages, and punitive damages. Plaintiff further demands interest and all costs of this action. Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: CERTIFICATE OF SERVICE - 2 - 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____. _________________________________ - 3 -