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DO NOT FILE WITH THE COURT THIS IS NOT AN ANSWER OR RESPONSE TO THE COMPLAINT DISC-010 SUPERIOR COURT OF CALIFORNIA, COUNTY OF PLAINTIFF (Name): DEFENDANT(Name): CASE NUMBER: CASE QUESTIONNAIRE - FOR LIMITED CIVIL CASES (UNDER $25,000 Requesting Party (name): Responding Party (name): — INSTRUCTIONS — A. The p urp ose o f th e c a se q uestio nnair e is to h elp th e p artie s s e ttle th eir d if fe re nce s w it h out s p endin g a lo t o f mo ney. T his is a cco m plis h ed b y e xch angin g in fo rm atio n a bout th e c a se e arly in th e la w su it . T he e xch ange o f ca se q uestio nnair e s m ay b e s ta rte d o nly b y a p la in tif f ( o r c ro ss-c o m pla in ant) in a lim it e d c iv il c a se . T he c a se qu estio nnair e is o ptio nal a nd if p la in tif f ( o r c ro ss-c o m pla in ant) e xce rc is e s th is o ptio n o nly th is fo rm m ay b e u se d.B . In str u ctio n s f o r p la in tif fs ( a n d c ro ss-c o m pla in an ts )1. Under C ode o f C iv il P ro ce dure s e ctio n 9 3, a p la in tif f (o r c ro ss-c o m pla in ant) m ay s e rv e a c o m ple te d ca se q uestio nnair e a nd a b la nk c a se q uestio nnair e w it h th e c o m pla in t ( o r c ro ss-c o m pla in t) .2 . This is th e o nly w ay y o u c a n re quir e d efe ndants (o r c ro ss-d efe ndants ) to s e rv e y o u w it h a c o m ple te d ca se q uestio nnair e .C . In str u ctio n s f o r d efe n dan ts ( a n d c ro ss-d efe n dan ts )1. If y o u h ave b een s e rv e d w it h a c o m ple te d c a se q uestio nnair e b y a p la in tif f ( o r c ro ss-c o m pla in ant) , th en yo u m ust fill in th e b la nk c a se q uestio nnair e . Y our c o m ple te d c a se q uestio nnair e m ust b e s e rv e d o n th e r e questin g p la in tif f ( o r c ro ss-c o m pla in ant) w it h y o ur a nsw er to th e c o m pla in t ( o r c ro ss-c o m pla in t) .2 . TH IS I S N O T A N A NSW ER O R R ESPO NSE T O T H E C O M PLA IN T.D In str u ctio n s f o r a ll p artie s1 . ALL Q UES TIO NS R EFE R T O T H E I N CID EN T O R A G REE M EN T I N T H IS L A W SU IT O NLY .2. Answ er e ach q uestio n. I f a q u estio n is n ot a pplic a ble , a nsw er " N A."3 . Your a nsw ers a re n ot lim it e d to y o ur p ers o nal k n ow le dge, b ut y o u a re re quir e d to fu rn is h in fo rm atio n av a ila ble to yo u or anyo ne actin g on yo ur behalf , w heth er yo u are a pla in tif f, defe ndant, cro ss- co m pla in ant, o r c ro ss-d efe ndant.4 . Typ e o r le gib ly p rin t y o ur a nsw er b elo w e ach q uestio n. If y o u c a nnot c o m ple te ly a nsw er a q uestio n in the s p ace p ro vid ed o n th e c a se q uestio nnair e , c h eck th e "a tta ch m ent" b ox a nd p ut th e n um ber o f th e qu estio n a nd th e c o m ple te a nsw er o n a n a tta ch ed s h eet o f p aper o r fo rm M C-0 25. Y ou s h ould n ot p ut pa rt o f a n a n sw er o n th e c a se q uestio nnair e a nd p art o n th e a tta ch m ent. Y ou m ay p ut m ore th an o ne answ er o n e a ch a tta ch ed p age .5 . When y o u h a ve c o m ple te d th e c a se q uestio nnair e , s ig n th e v e rif ic a tio n a nd s e rv e th e o rig in al.6 . You m ay c o m pel c o m plia nce w it h th ese r e quir e m ents u nder C ode o f C iv il P ro ce dure s e ctio n 9 3.7 . DO N O T F IL E T H IS C ASE Q UESTIO NNAIR E W IT H T H E C O URT. CASE QUESTIONNAIRE- FOR LIMITED CIVIL CASES (UNDER $25,000) Code of Civil Procedure § 93 Form Adopted by for Manditory Use Judicial Council of California DISC-010 [Rev. January 1, 2007]page1 of 1e le ctr o nic f o rm  2 002 WWW.LawCA.com La w P ublis h ers DO NOT FILE WITH THE COURT PLAINTIFF (Name): DEFENDANT(Name): CASE NUMBER: – QUESTIONS – 1.FOR ALL CASESa. State your name and street address. b. State your current business name and street address, type of business entity, and your title. c. Describe in detail your claims or defenses and the facts on which they are based, giving relevant dates. See attachment for answer number 1c. d. State the name, street address, and telephone number of each person who has knowledge of facts relating to this lawsuit and specify his or her area of knowledge. See attachment for answer number 1d. e. Describe each document or photograph that relates to the issues or facts. You are encouraged to attach a copy of each. For each that you have described but not attached, state the name, street address, and telephone number of each person who has it. See attachment for answer number 1e. CASE QUESTIONNAIRE Page two of four DISC-010 [Rev. January 1, 2007]ele ctr o nic f o rm  2 002 WWW.LawCA.com La w P ublis h ers DISC-010 PLAINTIFF (Name): DEFENDANT(Name): CASE NUMBER: 1. f.Describe each item of physical evidence that relates to the issues and facts, give its location, and state the name, street address, and telephone number of each person who has it. See attachment for answer number 1f. g. State the name and street address of each insurance company and the number of each policy that may cover you in whole or part for the damages claimed. See attachment for answer number 1g. 2. FOR PERSONAL INJURY OR PROPERTY DAMAGE CASESa.Describe each injury or Illness that you received and your present complaints about each. See attachment for answer number 2a. b. State the name, street address, and telephone umber of each physician, dentist, or other health care provider who treated or examined you, the type of treatment, the dates of treatment, and the charges by each to date. See attachment for answer number 2b. c. Itemize the medical expenses you anticipate in the future. See attachment for answer number 2c. d. Itemize your loss of income to date, give the name and street address of each source, and show how the loss is computed. See attachment for answer number 2d. CASE QUESTIONNAIRE Page three of four DISC-010 [Rev. January 1, 2007]ele ctr o nic f o rm  2 002 WWW.LawCA.com La w P ublis h ers DISC-010 PLAINTIFF (Name): DEFENDANT(Name): CASE NUMBER: 2. e.Itemize the loss of income you anticipate in the future, give the name and street address of each source, and show how the loss is computed. See attachment for answer number 2e. f. Itemize your property damage and state the amount or attach an itemized bill or estimate. See attachment for answer number 2f. g. Describe each other item of damage or cost that you claim and state the amount. See attachment for answer number 2g. 3. FOR CASES BASED ON AGREEMENTSa.In addition to your answer to 1e, state all the terms and give the date of any part of the agreement that is not in writing. See attachment for answer number 3a. b. Describe each item of damage or cost you claim, state the amount, and show how it is computed. See attachment for answer number 3b. VERIFICATION I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.D ate : (TYPE OR PRINT NAME) (SIGNATURE) CASE QUESTIONNAIRE Page four of four DISC-010 [Rev. January 1, 2007]ele ctr o nic f o rm  2 002 WWW.LawCA.com La w P ublis h ers