Fill and Sign the Negligent Supervision Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) COMPLAINT COMES NOW PLAINTIFF, _______________, a minor, by and through her parents, _______________ and _______________, and files this her complaint against defendant, _______________, and would show unto this honorable court the following, to wit: I. That Plaintiff is a minor being 8 years of age, residing with her parents _______________ and _______________, who are adult resident citizens of _______________ County, _______________. II. The Defendant, _______________, is an adult resident citizen of _______________ County, _______________, who may be served with process of this court at ______________________________, _______________. III. That on or about the _____ day of _______________, 20____, Plaintiff was in the care of - 2 - the defendant during a day of preparation for the Thanksgiving holidays, at which time defendant directed Plaintiff to clean windows in the home of defendant using a swivel barstool to stand upon to reach the top of a glass door she was cleaning. The top of the stool swiveled and the plaintiff fell, resulting in traumatic injuries. IV. The defendant had a duty to the child to use reasonable care to protect her from harm. The defendant failed to direct the plaintiff in what method should be used to reach the top of a glass door, which caused a breach of that duty. V. Defendant negligently allowed the plaintiff, a child of tender years, to use a swi vel barstool to stand on, which resulted as the proximate cause of the injuries sustained by the plaintiff. VI. As a direct result of the negligence of the defendant, plaintiff received severe injuri es, pain and suffering, and medical and hospital expenses. WHEREFORE, Plaintiff, sustained serious, painful and permanent injuries to her body, from which she has suffered, and will continue to suffer, with much pain, from which she has incurred, and will continue to incur, hospital, medical and drug expenses. WHEREFORE, Plaintiff demands judgment against defendant for all damages allowed by law and in an amount to be determined by a jury. - 3 - 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____. _________________________________