Fill and Sign the Shopping Cart Injury Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) AMENDED COMPLAINT COMES NOW the Plaintiff, _______________, by and through counsel, and files this civil action against the Defendant, _______________, and would most respectfully show unto the Court the following: 1. Plaintiff is a bona fide adult resident citizen of _______________ County, _______________, whose residence address is _______________, _______________. Defendant, _______________ d/b/a _______________, is a corporation organized and existing by virtue of the laws of the State of _______________, upon which service of process may be had on its registered agent, _______________, at _______________, _______________. 2. On the _____ day of ___________, 20___, Plaintiff was a patron of said _______________ grocery store owned and operated by the Defendant herein, at which time she purchased numerous food and household items for her personal utilization. 3. After tendering payment for all goods purchased by the Plaintiff herein, an employee and agent of the Defendant, _______________ d/b/a _______________ escorted - 1 - Plaintiff to her vehicle in order to assist her in transferring the grocery bags from a shopping cart to her automobile. At the aforesaid place and time, the Defendant's employee and agent negligently veered the shopping cart which she was directing into the Plaintiff's right heel and ankle. 4. At all times material herein, the unidentified female employee of the Defendant was acting within the course and scope of her employment with the Defendant herein and in furtherance of the Defendant's business. 5. The Plaintiff charges and alleges that it was the duty of the Defendant’s servant, agent or employee to utilize such reasonable and proper control of the shopping cart so as to not cause personal injury to the Plaintiff herein. 6. As a direct and proximate result of the negligence of Defendant's employee and agent, Plaintiff has suffered injuries damages as hereinafter enumerated: a. Plaintiff has suffered and will continue to suffer severe and disabling permanent injury; b. Plaintiff has suffered and will continue to suffer severe physical pain; c. Plaintiff has required the services of physicians and the administering of drugs and has incurred medical, hospital and drug expenses in an attempt to alleviate pain and suffering; d. Plaintiff has suffered and will continue to suffer mental pain and anguish; and e. Plaintiff has suffered the loss of use and enjoyment of her vehicle. WHEREFORE, PREMISES CONSIDERED, Plaintiff sues and demands judgment of and from the Defendant, _______________ d/b/a _______________, the full sum of _______________ DOLLARS ($_______________), together with all costs herein. - 2 - 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____. _________________________________ - 3 -