Fill and Sign the Injury Complaint Sample 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 employed by _____________, in ________________, __________________, 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 (provide detailed facts giving rise to cause of action) …… 5. Plaintiff would show that Defendant (describe specific cause of action based upon facts provided above) ….. 6. As a proximate result of these breaches of duty, Plaintiff (provide description of remedy sought) …. - 1 - WHEREFORE, PREMISES CONSIDERED, Plaintiff files this suit and demands judgment of and from the Defendant for actual / compensatory / punitive damages (select applicable award type) . 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 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____. _________________________________ - 2 -