PI/PD - Complaint

SAMPLE
Use the samples to help you complete
the packet of blank forms.
 CM-010
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

YOUR NAME
YOUR STREET ADDRESS
YOUR CITY, STATE, ZIP CODE
TELEPHONE NO.: YOUR PHONE# FAX NO.:
ATTORNEY FOR (Name): IN PRO PER

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA

STREET ADDRESS: CHECK WITH STAFF
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME: CIVIL
CASE NAME: YOUR LAST NAME vs.
LAST NAME OF THE PERSON YOU ARE SUING
CIVIL CASE COVER SHEET Complex Case Designation CASE NUMBER:
 Unlimited  Limited LEAVE BLANK
(Amount (Amount  Counter  Joinder
JUDGE: LEAVE BLANK
demanded demanded is Filed with first appearance by defendant
Check the box with the
exceeds $25,000) $25,000 or less) (Cal. Rules of Court, rule 3.402) DEPT.: LEAVE BLANK
Items 1-6 below must be completed (see instructions on page 2).
1.amount you
Check one box are
belowsuing for type that best describes this case:
for the case
Auto Tort Contract Provisionally Complex Civil Litigation
 Auto (22)  Breach of contract/warranty (06) (Cal. Rules of Court, rules 3.400-3.403)
 Uninsured motorist (46)  Rule 3.740 collections (09)  Antitrust/Trade regulation (03)
Other PI/PD/WD (Personal Injury/Property  Other collections (09)  Construction defect (10)
Damage/Wrongful Death) Tort  Insurance coverage (18)  Mass tort (40)

 Asbestos (04)  Other contract (37)  Securities litigation (28)

 Product liability (24) Real Property  Environmental/Toxic tort (30)

 Medical malpractice (45)  Eminent domain/Inverse  Insurance coverage claims arising from the
above listed provisionally complex case
 Other PI/PD/WD (23) condemnation (14)
types (41)
Non-PI/PD/WD (Other) Tort  Wrongful eviction (33)
 Business tort/unfair business practice (07)  Other real property (26) Enforcement of Judgment

 Civil rights (08) Unlawful Detainer  Enforcement of judgment (20)

 Defamation (13)  Commercial (31) Miscellaneous Civil Complaint
 Fraud (16)  Residential (32)  RICO (27)
 Intellectual property (19)  Drugs (38)  Other complaint (not specified above) (42)
 Professional negligence (25) Judicial Review Miscellaneous Civil Petition
 Other non-PI/PD/WD tort (35)  Asset forfeiture (05)  Partnership and corporate governance (21)
Employment  Petition re: arbitration award (11)  Other petition (not specified above) (43)
 Wrongful termination (36)  Writ of mandate (02)
 Other employment (15)  Other judicial review (39) CHECK THE CORRECT BOX(ES)
2. This case  is  is not complex under rule 3.400 of the California Rules of Court. If the case is complex, mark the
factors requiring exceptional judicial management:
a.  Large CHECK BOX
number "c." IF YOU
of separately ARE ASKING
represented parties d.  Large number of witnesses
b.  Extensive motion practice raising difficult or novel e.  Coordination with related actions pending in one or more courts
FORthat
issues PUNITIVE DAMAGESto resolve
will be time-consuming in other counties, states, or countries, or in a federal court
c.  Substantial amount of documentary evidence f.  Substantial postjudgment judicial supervision
3. Remedies sought (check all that apply): a.   monetary b.  nonmonetary; declaratory or injunctive relief c.  punitive
4. Number of causes of action (specify): # OF CAUSES OF ACTION ATTACHED
5. This case  is   is not a class action suit.
6. If there are any known related cases, file and serve a notice of related case. (You may use form CM-015.)

TODAY'S DATE
Date:
PRINT YOUR NAME
(TYPE OR PRINT NAME)
SIGN YOUR NAME
(SIGNATURE OF PARTY OR ATTORNEY FOR PARTY)

NOTICE

Plaintiff must file this cover sheet with the first paper filed in the action or proceeding (except small claims cases or cases filed
under the Probate Code, Family Code, or Welfare and Institutions Code). (Cal. Rules of Court, rule 3.220.) Failure to file may result
in sanctions.

File this cover sheet in addition to any cover sheet required by local court rule.

If this case is complex under rule 3.400 et seq. of the California Rules of Court, you must serve a copy of this cover sheet on all
other parties to the action or proceeding.

Unless this is a collections case under rule 3.740 or a complex case, this cover sheet will be used for statistical purposes only.
Page 1 of 2

Form Adopted for Mandatory Use

Judicial Council of California
CIVIL CASE COVER SHEET Cal. Rules of Court, rules 2.30, 3.220, 3.400-3.403, 3.740;
Cal. Standards of Judicial Administration, std. 3.10
CM-010 [Rev. July 1, 2007] www.courtinfo.ca.gov
SHC SAMPLE
 CM-010
INSTRUCTIONS ON HOW TO COMPLETE THE COVER SHEET
To Plaintiffs and Others Filing First Papers. If you are filing a first paper (for example, a complaint) in a civil case, you must
complete and file, along with your first paper, the Civil Case Cover Sheet contained on page 1. This information will be used to compile
statistics about the types and numbers of cases filed. You must complete items 1 through 6 on the sheet. In item 1, you must check
one box for the case type that best describes the case. If the case fits both a general and a more specific type of case listed in item 1,
check the more specific one. If the case has multiple causes of action, check the box that best indicates the primary cause of action.
To assist you in completing the sheet, examples of the cases that belong under each case type in item 1 are provided below. A cover
sheet must be filed only with your initial paper. Failure to file a cover sheet with the first paper filed in a civil case may subject a party,
its counsel, or both to sanctions under rules 2.30 and 3.220 of the California Rules of Court.
To Parties in Rule 3.740 Collections Cases. A "collections case" under rule 3.740 is defined as an action for recovery of money
owed in a sum stated to be certain that is not more than $25,000, exclusive of interest and attorney's fees, arising from a transaction in
which property, services, or money was acquired on credit. A collections case does not include an action seeking the following: (1) tort
damages, (2) punitive damages, (3) recovery of real property, (4) recovery of personal property, or (5) a prejudgment writ of
attachment. The identification of a case as a rule 3.740 collections case on this form means that it will be exempt from the general
time-for-service requirements and case management rules, unless a defendant files a responsive pleading. A rule 3.740 collections
case will be subject to the requirements for service and obtaining a judgment in rule 3.740.
To Parties in Complex Cases. In complex cases only, parties must also use the Civil Case Cover Sheet to designate whether the
case is complex. If a plaintiff believes the case is complex under rule 3.400 of the California Rules of Court, this must be indicated by
completing the appropriate boxes in items 1 and 2. If a plaintiff designates a case as complex, the cover sheet must be served with the
complaint on all parties to the action. A defendant may file and serve no later than the time of its first appearance a joinder in the
plaintiff's designation, a counter-designation that the case is not complex, or, if the plaintiff has made no designation, a designation that
the case is complex.
CASE TYPES AND EXAMPLES
Auto Tort Contract
Breach of Contract/Warranty (06) Provisionally Complex Civil Litigation (Cal.
Auto (22)-Personal Injury/Property Rules of Court Rules 3.400-3.403)
Damage/Wrongful Death Breach of Rental/Lease
Contract (not unlawful detainer Antitrust/Trade Regulation (03)
Uninsured Motorist (46) (if the Construction Defect (10)
case involves an uninsured or wrongful eviction)
Contract/Warranty Breach-Seller Claims Involving Mass Tort (40)
motorist claim subject to Securities Litigation (28)
arbitration, check this item Plaintiff (not fraud or negligence)
Negligent Breach of Contract/ Environmental/Toxic Tort (30)
instead of Auto) Insurance Coverage Claims
Warranty
Other PI/PD/WD (Personal Injury/ Other Breach of Contract/Warranty (arising from provisionally complex
Property Damage/Wrongful Death) Collections (e.g., money owed, open case type listed above) (41)
Tort book accounts) (09) Enforcement of Judgment
Asbestos (04) Collection Case-Seller Plaintiff Enforcement of Judgment (20)
Asbestos Property Damage Other Promissory Note/Collections Abstract of Judgment (Out of
Asbestos Personal Injury/ Case County)
Wrongful Death Insurance Coverage (not provisionally Confession of Judgment (non-
Product Liability (not asbestos or complex) (18) domestic relations)
toxic/environmental) (24) Auto Subrogation Sister State Judgment
Medical Malpractice (45) Other Coverage Administrative Agency Award
Medical Malpractice- Other Contract (37) (not unpaid taxes)
Physicians & Surgeons Contractual Fraud Petition/Certification of Entry of
Other Professional Health Care Other Contract Dispute Judgment on Unpaid Taxes
Malpractice Real Property Other Enforcement of Judgment
Other PI/PD/WD (23) Eminent Domain/Inverse Case
Premises Liability (e.g., slip Condemnation (14) Miscellaneous Civil Complaint
and fall) Wrongful Eviction (33) RICO (27)
Intentional Bodily Injury/PD/WD Other Real Property (e.g., quiet title) (26) Other Complaint (not specified
(e.g., assault, vandalism) Writ of Possession of Real Property above) (42)
Intentional Infliction of Mortgage Foreclosure Declaratory Relief Only
Emotional Distress Quiet Title Injunctive Relief Only (non-
Negligent Infliction of Other Real Property (not eminent harassment)
Emotional Distress domain, landlord/tenant, or Mechanics Lien
Other PI/PD/WD foreclosure) Other Commercial Complaint
Non-PI/PD/WD (Other) Tort Case (non-tort/non-complex)
Unlawful Detainer Other Civil Complaint
Business Tort/Unfair Business Commercial (31)
Practice (07) (non-tort/non-complex)
Residential (32)
Civil Rights (e.g., discrimination, Drugs (38) (if the case involves illegal Miscellaneous Civil Petition
false arrest) (not civil drugs, check this item; otherwise, Partnership and Corporate
harassment) (08) report as Commercial or Residential) Governance (21)
Defamation (e.g., slander, libel) Other Petition (not specified
(13) Judicial Review above) (43)
Fraud (16) Asset Forfeiture (05) Civil Harassment
Intellectual Property (19) Petition Re: Arbitration Award (11) Workplace Violence
Professional Negligence (25) Writ of Mandate (02) Elder/Dependent Adult
Legal Malpractice Writ-Administrative Mandamus Abuse
Writ-Mandamus on Limited Court Election Contest
Other Professional Malpractice Case Matter
(not medical or legal) Petition for Name Change
Writ-Other Limited Court Case Petition for Relief from Late
Other Non-PI/PD/WD Tort (35) Review Claim
Employment Other Judicial Review (39) Other Civil Petition
Wrongful Termination (36) Review of Health Officer Order
Other Employment (15) Notice of Appeal-Labor
Commissioner Appeals
CM-010 [Rev. July 1, 2007] CIVIL CASE COVER SHEET Page 2 of 2
 NAME OF PERSON/COMPANY YOU ARE SUING

YOUR NAME

LEAVE BLANK
SUPERIOR COURT OF CALIFORNIA, SANTA CLARA COUNTY
CHECK WITH STAFF

YOUR NAME YOUR PHONE #

YOUR ADDRESS

Check "1." if you are suing a person, not a company.

Check "3." if you are suing a company, not an individual

person. Select a box below that best identifies them/it.
 PLD-PI-001
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address) : FOR COURT USE ONLY

YOUR NAME
YOUR STREET ADDRESS
YOUR CITY, STATE, ZIP CODE
TELEPHONE NO.: YOUR PHONE # FAX NO.(Optional) :
E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name): IN PRO PER

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
STREET ADDRESS: CHECK WITH STAFF
MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME: CIVIL

PLAINTIFF: YOUR NAME

DEFENDANT: PERSON/COMPANY YOU ARE SUING

 DOES 1 TO 5


COMPLAINT-Personal Injury, Property Damage, Wrongful Death

AMENDED (Number) : CHECK ALL THE BOXES THAT APPLY
Type (check all that apply) :

MOTOR VEHICLE
OTHER (specify) :

Property Damage
Wrongful Death

Personal Injury
Other Damages (specify) :
Jurisdiction (check all that apply) : CASE NUMBER:


ACTION IS A LIMITED CIVIL CASE LEAVE BLANK
Amount demanded
does not exceed $10,000 CHECK THE CORRECT BOX

exceeds $10,000, but does not exceed $25,000

ACTION IS AN UNLIMITED CIVIL CASE (exceeds $25,000)

ACTION IS RECLASSIFIED by this amended complaint

from limited to unlimited

from unlimited to limited
1. Plaintiff (name or names): YOUR NAME

alleges causes of action against defendant (name or names): PERSON/COMPANY YOU ARE SUING

2. This pleading, including attachments and exhibits, consists of the following number of pages: #

IF YOU ARE SUING A PERSON, NOT A

3. Each plaintiff named above is a competent adult
a.
except plaintiff (name) :
COMPANY, LEAVE "3(a)" AND "3(b)" BLANK
(1)
a corporation qualified to do business in California
(2)
an unincorporated entity (describe) :
(3)
a public entity (describe) : IF YOU ARE SUING A COMPANY(IES), FILL
(4)
a minor
an adult
(a)
for whom a guardian or conservator of IN ITEM
the estate or a "3(a)"
guardian AND/OR "3(b)"
ad litem has been WITH
appointed
(b)
other (specify) : INFORMATION ABOUT THE COMPANY(IES)
(5)
other (specify) :

b.
except plaintiff (name) :

(1)
a corporation qualified to do business in California
(2)
an unincorporated entity (describe) :
(3)
a public entity (describe) :
(4)
a minor
an adult
(a)
for whom a guardian or conservator of the estate or a guardian ad litem has been appointed
(b)
other (specify) :
(5)
other (specify) :

Information about additional plaintiffs who are not competent adults is shown in Attachment 3. Page 1 of 3
Form Approved for Optional Use
Judicial Council of California
COMPLAINT-Personal Injury, Property Code of Civil Procedure, § 425.12
www.courtinfo.ca.gov
PLD-PI-001 [Rev. January 1, 2007] Damage, Wrongful Death SHC/FLF- SAMPLE
 PLD-PI-001
SHORT TITLE: CASE NUMBER:
YOUR NAME vs. PERSON/COMPANY YOU ARE SUING LEAVE BLANK
4.
Plaintiff (name) :
is doing business under the fictitious name (specify) :

and has complied with the fictitious business name laws.

5. SKIP THIS QUESTION IF YOU ARE
Each defendant named above is a natural person SUING
a.
except defendant (name) : A PERSON, NOTc.
Aexcept
COMPANY
defendant (name) :

(1)
a business organization, form unknown (1)
a business organization, form unknown
(2)
a corporation (2)
a corporation
(3)
an unincorporated entity (describe) : (3)
an unincorporated entity (describe) :
(4)
a public entity (describe) : (4)
a public entity (describe) :
(5)
other (specify) : (5)
other (specify) :

b.
except defendant (name) : d.
except defendant (name) :

(1)
a business organization, form unknown (1)
a business organization, form unknown
(2)
a corporation (2)
a corporation
(3)
an unincorporated entity (describe) : (3)
an unincorporated entity (describe) :
(4)
a public entity (describe) : (4)
a public entity (describe) :
(5)
other (specify) : (5)
other (specify) :

CHECK WITH STAFF

Information about additional defendants who are not natural persons is contained in Attachment 5.
6. The true names of defendants sued as Does are unknown to plaintiff.
a.
Doe defendants (specify Doe numbers): were the agents or employees of other
named defendants and acted within the scope of that agency or employment.
b.
Doe defendants (specify Doe numbers): are persons whose capacities are unknown to
plaintiff.
7.
Defendants who are joined under Code of Civil Procedure section 382 are (names):

8. This court is the proper court because

a.
at least one defendant now resides in its jurisdictional area.
b.
the principal place of business of a defendant corporation or unincorporated association is in its jurisdictional area.
c.
 injury to person or damage to personal property occurred in its jurisdictional area.
d.
other (specify):

CHECK WITH STAFF

9.
Plaintiff is required to comply with a claims statute, and

a.
has complied with applicable claims statutes, or
b.
is excused from complying because (specify):

PLD-PI-001 [Rev. January 1, 2007] COMPLAINT-Personal Injury, Property Page 2 of 3

Damage, Wrongful Death SHC/FLF- SAMPLE

 PLD-PI-001
SHORT TITLE: CASE NUMBER:
YOUR NAME vs. PERSON/COMPANY YOU ARE SUING LEAVE BLANK

10. The following causes of action are attached and the statements above apply to each (each complaint must have one or more
causes of action attached) :
a.
Motor Vehicle
b.
General Negligence
c.
Intentional Tort CHECK ALL THAT APPLY. REMEMBER THAT YOU MUST
d.
Products Liability HAVE A "CAUSE OF ACTION" FORM FOR EVERY ITEM
e.
Premises Liability
f.
Other (specify) :
YOU HAVE CHECKED.

11. Plaintiff has suffered

a.
wage loss
b.
loss of use of property
c.
hospital and medical expenses
d.
general damage
e.
property damage
CHECK ALL THAT APPLY
f.
loss of earning capacity
g.
other damage (specify) :
CHECK "g." IF YOU WANT TO ASK FOR PUNITIVE DAMAGES

12.
The damages claimed for wrongful death and the relationships of plaintiff to the deceased are
a.
listed in Attachment 12.
b.
as follows:

13. The relief sought in this complaint is within the jurisdiction of this court.

14. Plaintiff prays for judgment for costs of suit; for such relief as is fair, just, and equitable; and for
a. (1)
 compensatory damages CHECK ONLY IF YOU WANT PUNITIVE DAMAGES
(2)
punitive damages
The amount of damages is (in cases for personal injury or wrongful death, you must check (1)):
(1)
according to proof HOW MUCH ARE YOU SUING FOR?
(2)
 in the amount of: $

15.  The paragraphs of this complaint alleged on information and belief are as follows

(specify paragraph numbers) :
IF ANY STATEMENTS IN YOUR CAUSE(S) OF ACTION ARE BASED ON BELIEF,
NOT YOUR OWN FIRST - HAND KNOWLEDGE, WRITE THOSE PARAGRAPH
NUMBERS HERE.

TODAY'S DATE
Date:
PRINT YOUR NAME ' SIGN YOUR NAME
(TYPE OR PRINT NAME) (SIGNATURE OF PLAINTIFF OR ATTORNEY)

PLD-PI-001 [Rev. January 1, 2007] COMPLAINT-Personal Injury, Property Page 3 of 3

Damage, Wrongful Death

SHC/FLF- SAMPLE
 PLD-PI-001(1)
SHORT TITLE: CASE NUMBER:
YOUR NAME vs. PERSON/COMPANY YOU ARE SUING LEAVE BLANK

FIRST, SECOND, THIRD, etc.CAUSE OF ACTION- Motor Vehicle

(number)
**NOTE: USE THIS FORM ONLY IF YOUR INJURY
ATTACHMENT TO
 Complaint
Cross-Complaint RESULTED FROM AN AUTOMOBILE ACCIDENT.
(Use a separate cause of action form for each cause of action.) OTHERWISE, RIP THIS PAGE OUT.

Plaintiff (name): YOUR NAME

MV-1. Plaintiff alleges the acts of defendants were negligent; the acts were the legal (proximate) cause of injuries
and damages to plaintiff; the acts occurred
on (date):
DATE OF ACCIDENT
at (place):

WHERE DID THE ACCIDENT TAKE PLACE?

MV-2. DEFENDANTS
 The defendants who operated a motor vehicle are (names):
a.

NAME AND ADDRESS OF DRIVER

Does to
b.
The defendants who employed the persons who operated a motor vehicle in the course of their employment
are (names): CHECK "b." AND WRITE NAME AND ADDRESS OF COMPANY IF
DRIVER WAS DRIVING A COMPANY-OWNED VEHICLE

Does to
c.
The defendants who owned the motor vehicle which was operated with their permission are (names):

CHECK "c." AND WRITE NAME OF OWNER OF VEHICLE, IF DIFFERENT

FROM PERSON IN "A."

Does to
d.
The defendants who entrusted the motor vehicle are (names):

CHECK "d." IF YOU ANSWERED "b." OR "c.", WRITE THE NAME(S) FROM
"b." AND "c." HERE

Does to
e.
The defendants who were the agents and employees of the other defendants and acted within the scope
of the agency were (names):

CHECK "e." AND FILL IN THIS SECTION IF IT APPLIES.

Does to
f.
The defendants who are liable to plaintiffs for other reasons and the reasons for the liability are

listed in Attachment MV-2f
as follows:

SEE A PRIVATE ATTORNEY IF YOU HAVE QUESTIONS REGARDING "f."

Does to 4
Page
Page 1 of 1
Form Approved for Optional Use Code of Civil Procedure § 425.12
Judicial Council of California CAUSE OF ACTION - Motor Vehicle www.courtinfo.ca.gov
PLD-PI-001(1) [Rev. January 1, 2007]
SHC/FLF- SAMPLE
 PLD-PI-001(2)
SHORT TITLE: CASE NUMBER:

YOUR NAME vs. PERSON/COMPANY YOU ARE SUING LEAVE BLANK

FIRST, SECOND, THIRD, etc.CAUSE OF ACTION- General Negligence Page

(number)
ATTACHMENT TO
x Complaint
Cross-Complaint ** NOTE: USE THIS FORM ONLY IF THE PERSON YOU ARE
SUING COMMITTED A CARELESS OR NEGLIGENT ACT (AS
(Use a separate cause of action form for each cause of action.) OPPOSED TO AN INTENTIONAL ACT) IN A SITUATION
OTHER THAN A CAR OR PREMISES LIABILITY ACCIDENT.
OTHERWISE RIP THIS PAGE OUT.
GN-1. Plaintiff (name) : YOUR NAME

alleges that defendant (name) : PERSON/COMPANY YOU ARE SUING

Does to
was the legal (proximate) cause of damages to plaintiff. By the following acts or omissions to act, defendant
negligently caused the damage to plaintiff
on (date): DATE THAT YOU OR YOUR PROPERTY WHERE INJURED/DAMAGED
at (place): WHERE DID THE INJURY TAKE PLACE?
(description of reasons for liability) :
DESCRIBE WHAT HAPPENED THAT LED TO YOUR INJURY AND/OR
DAMAGE TO YOUR PROPERTY. EXPLAIN HOW THE PERSON YOU ARE
SUING IS RESPONSIBLE FOR CAUSING THIS.

Page 1 of 1
Form Approved for Optional Use CAUSE OF ACTION- General Negligence Code of Civil Procedure 425.12
Judicial Council of California www.courtinfo.ca.gov
PLD-PI-001(2) [Rev. January 1, 2007]

SHC/FLF- SAMPLE
 PLD-PI-001(3)
SHORT TITLE: CASE NUMBER
YOUR NAME vs. PERSON/COMPANY YOU ARE SUING LEAVE BLANK

FIRST, SECOND, THIRD, etc. CAUSE OF ACTION- Intentional Tort Page

(number) **NOTE: USE THIS FORM ONLY IF YOU
ATTACHMENT TO
 Complaint
Cross-Complaint FEEL THE PERSON YOU ARE SUING
INTENTIONALLY CAUSED YOUR INJURY.
(Use a separate cause of action form for each cause of action.) OTHERWISE, RIP THIS PAGE OUT.

IT-1. Plaintiff (name): YOUR NAME

alleges that defendant (name) : PERSON/COMPANY YOU ARE SUING

Does to
was the legal (proximate) cause of damages to plaintiff. By the following acts or omissions to act, defendant
intentionally caused the damage to plaintiff
on (date): DATE THAT YOU AND/OR YOUR PROPERTY WERE INJURED/DAMAGED
at (place): WHERE DID YOUR INJURY TAKE PLACE?

(description of reasons for liability):

DESCRIBE WHAT HAPPENED THAT LED TO YOUR INJURY AND/OR

DAMAGE TO YOUR PROPERTY. DESCRIBE HOW THE PERSON YOU ARE
SUING INTENTIONALLY CAUSED YOUR INJURY OR PROPERTY DAMAGE.

Page 1 of 1
Form Approved for Optional Use CAUSE OF ACTION - Intentional Tort Code of Civil Procedure, § 425.12
Judicial Council of California www.courtinfo.ca.gov
PLD-PI-001(3) [Rev. January 1, 2007]
SHC/FLF- SAMPLE
 PLD-PI-001(4)
SHORT TITLE: CASE NUMBER:

YOUR NAME VS PERSON/COMPANY YOU ARE SUING LEAVE BLANK

FIRST, SECOND, THIRD, etc.CAUSE OF ACTION - Premises Liability Page

(number)
ATTACHMENT TO
 Complaint
Cross-Complaint NOTE: USE THIS FORM IF YOU WERE INJURED
(Use a separate cause of action form for each cause of action.)
AT A BUSINESS OR HOME. OTHERWISE, RIP
THIS PAGE OUT.
Prem.L-1. Plaintiff (name): YOUR NAME
alleges the acts of defendants were the legal (proximate) cause of damages to plaintiff.
On (date): DATE OF INJURY plaintiff was injured on the following premises in the following
fashion (description of premises and circumstances of injury):

DESCRIBE HOW YOU WERE INJURED

Prem.L-2.  Count One-Negligence The defendants who negligently owned, maintained, managed and operated


the described premises were (names):
NAME OF OWNER OR MANAGER OF PROPERTY

 Does

1 to 5
Prem.L-3.
Count Two-Willful Failure to Warn [Civil Code section 846] The defendant owners who willfully or
maliciously failed to guard or warn against a dangerous condition, use, structure, or activity were
(names): (TALK TO A PRIVATE ATTORNEY IF YOU ARE UNSURE ABOUT THIS)

Does to
Plaintiff, a recreational user, was
an invited guest
a paying guest.

Prem.L-4.
Count Three-Dangerous Condition of Public Property The defendants who owned public property on
which a dangerous condition existed were (names):
(TALK TO A PRIVATE ATTORNEY IF YOU ARE UNSURE ABOUT THIS)

Does to
a.
The defendant public entity had
actual
constructive notice of the existence of the
dangerous condition in sufficient time prior to the injury to have corrected it.
b.
The condition was created by employees of the defendant public entity.

 Allegations about Other Defendants The defendants who were the agents and employees of the other
Prem.L-5. a.

defendants and acted within the scope of the agency were (names):
NAME OF EMPLOYEE(S) THAT CAUSED THE INJURY

 Does 1 to 5
b.
The defendants who are liable to plaintiffs for other reasons and the reasons for their liability are

described in attachment Prem.L-5.b
as follows (names):
(TALK TO A PRIVATE ATTORNEY IF YOU ARE UNSURE ABOUT THIS)

Page 1 of 1
Form Approved for Optional Use Code of Civil Procedure, § 425.12
Judicial Council of California CAUSE OF ACTION - Premises Liability www.courtinfo.ca.gov
PLD-PI-001(4) [Rev. January 1, 2007]
SHC/FLF- SAMPLE
 PLD-PI-001(6)
SHORT TITLE: CASE NUMBER:
YOUR NAME vs. PERSON/COMPANY YOU ARE SUING LEAVE BLANK

Exemplary Damages Attachment Page

**NOTE: USE THIS ONLY WHERE THE
PERSON YOU ARE SUING ACTED
ATTACHMENT TO  Complaint


Cross-Complaint OUTRAGEOUSLY TO CAUSE YOUR INJURY,
SPECIFICALLY, USE THIS ONLY IF THE
EX-1. As additional damages against defendant (name) : DEFENDANT ACTED OUT OF MALICE,
PERSON/COMPANY YOU ARE SUING FRAUD OR OPPRESSION (ASK STAFF IF YOU
NEED ASSISTANCE). OTHERWISE, RIP THIS
FORM OUT.
Plaintiff alleges defendant was guilty of

malice

fraud

oppression
as defined in Civil Code section 3294, and plaintiff should recover, in addition to actual damages, damages
to make an example of and to punish defendant.

EX-2. The facts supporting plaintiff's claim are as follows:

EXPLAIN HOW THE PERSON YOU ARE SUING ACTED OUT OF MALICE,
FRAUD OR OPPRESSION.
MALICE: DEFENDANT INTENDED TO MISREPRESENT OR HIDE AN
IMPORTANT FACT THAT HE/SHE KNEW ABOUT, WITH THE INTENTION OF
HARMING YOU OR TAKING ADVANTAGE OF YOU.
OPPRESSION: DEFENDANT INTENTIONALLY SUBJECTED YOU TO CRUEL
AND UNJUST HARDSHIP IN CONSCIOUS DISREGARD OF YOUR RIGHTS.

EX-3. The amount of exemplary damages sought is

 not shown, pursuant to Code of Civil Procedure section 425.10.
a.

b.
$
Page 1 of 1
Form Approved for Optional Use
Judicial Council of California
Exemplary Damages Attachment Code of Civil Procedure, § 425.12
www.courtinfo.ca.gov
PLD-PI-001(6) [Rev. January 1, 2007]

SHC/FLF- SAMPLE
 POS-010
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address) : FOR COURT USE ONLY

Your Name
Your Street Address
Your City, State and Zip
TELEPHONE NO.: Your Phone# FAX NO. (Optional):
E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name): IN PRO PER

SUPERIOR COURT OF CALIFORNIA, COUNTY OF Santa Clara
STREET ADDRESS: Check with Staff
MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME: Civil

PLAINTIFF/PETITIONER: Your Name CASE NUMBER:
Leave Blank
DEFENDANT/RESPONDENT: Name of person or company you are suing

Ref. No. or File No.:

PROOF OF SERVICE OF SUMMONS

(Separate proof of service is required for each party served.)

1. At the time of service I was at least 18 years of age and not a party to this action.
2. I served copies of:
a.
 summons
b.
 complaint
c.
 Alternative Dispute Resolution (ADR) package
d.
Civil Case Cover Sheet (served in complex cases only)
e.
cross-complaint
f.**NOTE:

other STOP HERE: THE
(specify documents) : PERSON WHO SERVES YOUR PAPERS WILL FILL OUT THE REST
OF THIS FORM.
3. a. Party served (specify name of party as shown on documents served) :
NAME OF PERSON/COMPANY YOU ARE SUING
b.
Person (other than the party in item 3a) served on behalf of an entity or as an authorized agent (and not a person
under item 5b on whom substituted service was made) (specify name and relationship to the party named in item 3a):

4. Address where the party was served: WRITE THE ADDRESS WHERE THE PERSON YOU ARE
SUING WAS GIVEN THE FORMS
5. I served the party (check proper box)
CHECK THE BOX "5.a." AND FILL IN THE DATE AND THE TIME THE OTHER PARTY WAS HANDED THE FORMS
a.
by personal service. I personally delivered the documents listed in item 2 to the party or person authorized to
receive service of process for the party (1) on (date) : DATE SERVED (2) at (time) : TIME SERVED
b.
by substituted service. On (date) : at (time) : I left the documents listed in item 2 with or
in the presence of (name and title or relationship to person indicated in item 3) :

(1)
(business) a person at least 18 years of age apparently in charge at the office or usual place of business
of the person to be served. I informed him or her of the general nature of the papers.
(2)
(home) a competent member of the household (at least 18 years of age) at the dwelling house or usual
place of abode of the party. I informed him or her of the general nature of the papers.
(3)
(physical address unknown) a person at least 18 years of age apparently in charge at the usual mailing
address of the person to be served, other than a United States Postal Service post office box. I informed
him or her of the general nature of the papers.
(4)
I thereafter mailed (by first-class, postage prepaid) copies of the documents to the person to be served
at the place where the copies were left (Code Civ. Proc., § 415.20). I mailed the documents on
(date) : from (city): or
a declaration of mailing is attached.
(5)
I attach a declaration of diligence stating actions taken first to attempt personal service.
Page 1 of 2
Form Adopted for Mandatory Use
Judicial Council of California
PROOF OF SERVICE OF SUMMONS Code of Civil Procedure, § 417.10
POS-010 [Rev. January 1, 2007]

SHC Sample
 PLAINTIFF/PETITIONER: Your Name CASE NUMBER:
Leave Blank
DEFENDANT/RESPONDENT: Name of person or company you are suing

5. c.
by mail and acknowledgment of receipt of service. I mailed the documents listed in item 2 to the party, to the
address shown in item 4, by first-class mail, postage prepaid,
(1) on (date) : (2) from (city) :
(3)
with two copies of the Notice and Acknowledgment of Receipt and a postage-paid return envelope addressed
to me. (Attach completed Notice and Acknowledgment of Receipt.) (Code Civ. Proc., § 415.30.)
(4)
to an address outside California with return receipt requested. (Code Civ. Proc., § 415.40.)
d.
by other means (specify means of service and authorizing code section) :

Additional page describing service is attached.

6. The "Notice to the Person Served" (on the summons) was completed as follows:
a.
as an individual defendant.
b.
as the person sued under the Check
fictitiousthe
namebox that: applies to your case
of (specify)
c.
as occupant.
d.
On behalf of (specify) : (this needs to match your Summons)
under the following Code of Civil Procedure section:

416.10 (corporation)
415.95 (business organization, form unknown)

416.20 (defunct corporation)
416.60 (minor)

416.30 (joint stock company/association)
416.70 (ward or conservatee)

416.40 (association or partnership)
416.90 (authorized person)

416.50 (public entity)
415.46 (occupant)

other:
7. Person who served papers
a. Name: NAME OF THE PERSON WHO SERVED THE PAPERS FOR YOU
b. Address: SERVER'S ADRESS (NOT YOURS!)
c. Telephone number: SERVER'S TELEPHONE NUMBER
d. The fee for service was: $
e. I am:
(1)
not a registered California process server.
Server
(2)
exempt from registration under checks
Business the box
and Professions that
Code applies
section to them
22350(b).
(3)
registered California process server:
(i)
owner
employee
independent contractor.
(ii) Registration No.:
(iii) County:
8.  I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.


or
9.
I am a California sheriff or marshal and I certify that the foregoing is true and correct.

Date: DATE SIGNED

SERVER PRINTS NAME ' SERVER SIGNS NAME

(NAME OF PERSON WHO SERVED PAPERS/SHERIFF OR MARSHAL) (SIGNATURE)

POS-010 [Rev. January 1, 2007] PROOF OF SERVICE OF SUMMONS Page 2 of 2

SHC Sample
 CIV-050
- DO NOT FILE WITH THE COURT -
- UNLESS YOU ARE APPLYING FOR A DEFAULT JUDGMENT UNDER CODE OF CIVIL PROCEDURE § 585 -
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address) : TELEPHONE NO.: FOR COURT USE ONLY
YOUR PHONE #

YOUR NAME
YOUR ADDRESS DO NOT FILL OUT
ATTORNEY FOR (Name) : SELF-REPRESENTED THIS FORM IF YOU
SANTA CLARA
ARE SUING FOR
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
CHECK WITH STAFF
STREET ADDRESS:

MAILING ADDRESS: 191 N. FIRST STREET PROPERTY DAMAGE

CITY AND ZIP CODE: SAN JOSE, CA 95113

BRANCH NAME: FAMILY

PLAINTIFF:YOUR NAME
DEFENDANT:PERSON/COMPANY YOU ARE SUING

CASE NUMBER:
STATEMENT OF DAMAGES
YOUR CASE NUMBER
(Personal Injury or Wrongful Death)
To (name of one defendant only) : PERSON/COMPANY YOU ARE SUING
Plaintiff (name of one plaintiff only) : YOUR NAME
seeks damages in the above-entitled action, as follows:
AMOUNT
1. General damages
a.
Pain, suffering, and inconvenience........................................................................................................$
CHECK ALL BOXES THAT APPLY
b.
Emotional distress .................................................................................................................................
$
AND FILL IN THE $AMOUNT
c.
Loss of consortium ................................................................................................................................
$
d.
Loss of society and companionship (wrongful death actions only) .................................................... $
e.
Other (specify) .......................................................................................................................................
$
f.
Other (specify) .......................................................................................................................................$
g.
Continued on Attachment 1.g.
2. Special damages
a.
Medical expenses (to date) ...................................................................................................................
$
b.
Future medical expenses (present value) ............................................................................................$
c.
Loss of earnings (to date) .....................................................................................................................
$
d.
Loss of future earning capacity (present value) ..................................................................................$
e.
Property damage....................................................................................................................................
$
f.
Funeral expenses (wrongful death actions only) .................................................................................$
g.
Future contributions (present value) (wrongful death actions only) ................................................... $
h.
Value of personal service, advice, or training (wrongful death actions only) ..................................... $
i.
Other (specify) .......................................................................................................................................
$
j.
Other (specify) .......................................................................................................................................
$
k.
Continued on Attachment 2.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: TODAY'S DATE

PRINT YOUR NAME ' SIGN YOUR NAME

(TYPE OR PRINT NAME) (SIGNATURE OF PLAINTIFF OR ATTORNEY FOR PLAINTIFF)
(Proof of service on reverse) Page 1 of 2

Form Adopted for Mandatory Use

Judicial Council of California
STATEMENT OF DAMAGES Code of Civil Procedure, §§ 425.11, 425.115
www.courtinfo.ca.gov
CIV-050 [Rev. January 1, 2007] (Personal Injury or Wrongful Death)
SHC/FLF SAMPLE
 CIV-050
PLAINTIFF: YOUR NAME CASE NUMBER:
YOUR CASE NUMBER
DEFENDANT:PERSON/COMPANY YOU ARE SUING
PROOF OF SERVICE
(After having the other party served as described below, with any of the documents identified in item 1, have the person who served
the documents complete this Proof of Service. Plaintiff cannot serve these papers.)

1. I served the
a.
Statement of Damages
Other (specify) :
b. on (name) :
c. by serving
defendant
other (name and title or relationship to person served) :
d.
by delivery
at home
at business
(1) date:
(2) time:
(3) address:

e.
by mailing
(1) date:
(2) place:
2. Manner of service (check proper box) :
a.
Personal service. By personally delivering copies. (CCP § 415.10)
b.
Substituted service on corporation, unincorporated association (including partnership), or public entity. By
leaving, during usual office hours, copies in the office of the person served with the person who apparently was in
charge and thereafter mailing (by first-class mail, postage prepaid) copies to the person served at the place where the
copies were left. (CCP § 415.20(a))
c.
Substituted service on natural person, minor, conservatee, or candidate. By leaving copies at the dwelling house,
usual place of abode, or usual place of business of the person served in the presence of a competent member of the
household or a person apparently in charge of the office or place of business, at least 18 years of age, who was
informed of the general nature of the papers, and thereafter mailing (by first-class mail, postage prepaid) copies to the
person served at the place where the copies were left. (CCP § 415.20 (b)) (Attach separate declaration or affidavit
stating acts relied on to establish reasonable diligence in first attempting personal service.)

d.
Mail and acknowledgment service. By mailing (by first-class mail or airmail, postage prepaid) copies to the person
served, together with two copies of the form of notice and acknowledgment and a return envelope, postage prepaid,
addressed to the sender. (CCP § 415.30) (Attach completed acknowledgment of receipt.)
e.
Certified or registered mail service. By mailing to an address outside California (by first-class mail, postage prepaid,
requiring a return receipt) copies to the person served. (CCP § 415.40) (Attach signed return receipt or other
evidence of actual delivery to the person served.)
f.
Other (specify code section) :

additional page is attached.
3. At the time of service I was at least 18 years of age and not a party to this action.
4. Fee for service: $
5. Person serving:
a.
California sheriff, marshal, or constable f. Name, address, and telephone number and, if applicable,
b.
Registered California process server county of registration and number:
c.
Employee or independent contractor of a registered
California process server
d.
Not a registered California process server
e.
Exempt from registration under Bus. & Prof. Code
§ 22350(b)
I declare under penalty of perjury under the laws of the State (For California sheriff, marshal or constable use only)
of California that the foregoing is true and correct. I certify that the foregoing is true and correct.
Date: Date:

' '
(SIGNATURE) (SIGNATURE)
CIV-050 [Rev. January 1, 2007] PROOF OF SERVICE Page 2 of 2
Code of Civil Procedure, §§ 425.11, 425.115
(Statement of Damages) SHC/FLF SAMPLE