CIV-050 Statement of Damages (Personal Injury or Wrongful Death)

- DO NOT FILE WITH THE COURT-
-UNLESS YOU ARE APPLYING FOR A DEFAULT JUDGMENT UNDER CODE OF CIVIL PROCEDURE § 585 -
TELEPHONE NO.: FOR COURT USE ONLY
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address):
ATTORNEY FOR (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PLAINTIFF:
DEFENDANT:
CASE NUMBER:
STATEMENT OF DAMAGES
(Personal Injury or Wrongful Death)
To (name of one defendant only):
Plaintiff (name of one plaintiff only):
seeks damages in the above-entitled action, as follows:
AMOUNT
1. General damages
Pain, suffering, and inconvenience ....................................................................................................
a.
$
Emotional distress. .............................................................................................................................
Loss of consortium .............................................................................................................................
b.
$
$
c.
Loss of sociey and companionship (wrongful death actions only) .....................................................
d.
$
Other (specify)e.
$
Other (specify)
f.
$
Continued on Attachment 1.g.
g.
2. Special damages
$
Medical expenses (to date) ................................................................................................................
a.
Future medical expenses (present value) ..........................................................................................
b.
$
$
Loss of earnings (to date) ...................................................................................................................
c.
Loss of future earning capacity (present value) ..................................................................................
d.
$
Property damage ................................................................................................................................
$
e.
$
Funeral expenses (wrongful death actions only) ................................................................................
f.
Future contributions (present value) (wrongful death actions only) ....................................................
g.
$
$Value of personal service, advice, or training (wrongful death actions only) ......................................
h.
$
Other (specify)
i.
$
Other (specify)
j.
Continued on Attachment 2.k.k.
3. Punitive damages: Plaintiff reserves the right to seek punitive damages in the amount of (specify).. $
when pursuing a judgment in the suit filed against you.
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF PLAINTIFF OR ATTORNEY FOR PLAINTIFF)
(Proof of service on reverse)
Form Adopted for Mandatory Use
Judicial Council of California
CIV-050 [Rev. January 1, 2007]
STATEMENT OF DAMAGES
(Personal Injury or Wrongful Death)
Code of Civil Procedure, §§ 425.11, 425.115
www.courtinfo.ca.gov
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
CIV-050
Page 1 of 2
To keep other people from 
seeing what you entered on 
your form, please press the 
Clear This Form button at the 
end of the form when finished.
Page 1/2
Free Download

CIV-050 Statement of Damages (Personal Injury or Wrongful Death) PDF

Favor this template? Just fancy it by voting!
  •  
  •  
  •  
  •  
  •  
(0 Votes)
0.0
Related Forms
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 902 Views | 5 Downloads
  •  
  •  
  •  
  •  
  •  
5 Page(s) | 1862 Views | 9 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1041 Views | 17 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1003 Views | 11 Downloads