COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. DO NOT FILE WITH THE COURT THIS IS NOT AN ANSWER OR RESPONSE TO THE COMPLAINT : Calendar No. DISC-010 SUPERIOR COURT OF CALIFORNIA, COUNTY OF Plaintiff(s) PLAINTIFF (Name): DEFENDANT (Name): -against- : CASE NUMBER JUDICIAL SUBPOENA : : CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES (Under $25,000) : REQUESTING PARTY (Name): RESPONDING.PARTY .(Name):. ........ ..... ..... Defendant(s) : ................................. —INSTRUCTIONS— THE PEOPLE OF THE STATE OF NEW YORK to help the parties settle their differences without spending a lot A. The purpose of the case questionnaire is TO of money. This is accomplished by exchanging information about the case early in the lawsuit. The exchange of case questionnaires may be started only by a plaintiff (or cross-complainant) in a limited civil case. The case questionnaire is optional, and if plaintiff (or cross-complainant) exercises the option, only this form may be used. B. Instructions for plaintiffs (and cross-complainants) GREETINGS: 1. Under Code of Civil Procedure section 93, a plaintiff (or cross-complainant) may serve a completed case questionnaire and a blank questionnaire with a complaint (or cross-complaint). WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 2. This is the only way you can require defendants (or cross-defendants) to serve you with a completed , the Honorable at the Court case questionnaire. located at County of C. in room Instructions for defendants (and cross-defendants) , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned If you to testify and give evidence as a witness in this action on the plaintiff the cross-complainant), date, have been served with a completed case questionnaire by a part of (or 1. then you must fill in the blank case questionnaire. Your completed case questionnaire must be served on that same plaintiff (or cross-complainant) with your answer to the complaint (or cross-complaint). 2. THIS IS NOT AN ANSWER OR RESPONSE TO THE COMPLAINT. court and will make you liable to Your failure to comply with this subpoena is punishable as a contempt of the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure tofor all parties D. Instructions comply. 1. ALL QUESTIONS REFER TO THE INCIDENT OR AGREEMENT IN THIS LAWSUIT ONLY. Witness, Honorable Court in County, , one of the Justices of the 2. Answer each question. If a question is not applicable, answer “NA.” day of , 20 3. Your answers are not limited to your personal knowledge, but you are required to furnish information available to you or to anyone acting on your behalf, whether you are a plaintiff, defendant, cross-complainant, or cross -defendant. (Attorney must sign above and type answer a question in 4. Type or legibly print your answer below each question. If you cannot completely name below) the space provided on the case questionnaire, check the “attachment” box and put the number of the question and the complete answer on an attached sheet of paper or form MC-025. You should not put part of an answer on the case questionnaire and part on the attachment. You may put more than one Attorney(s) for answer on each attached page. 5. When you have completed the case questionnaire, sign the verification and serve the original. 6. You may compel compliance with these requirements under Code of Civil Procedure section 93. 7. DO NOT FILE THIS CASE QUESTIONNAIRE WITH THEand P.O. Address Office COURT. Form Adopted for Mandatory Use Judicial Council of California DISC-010 [Rev. January 1, 2007] Telephone No.: Facsimile No.: E-Mail Address: CASE QUESTIONNAIRE—FOR LIMITED CIVIL No.: Mobile Tel. CASES Page 1 of 4 Code of Civil Procedure, § 93 www.courtinfo.ca.gov (Under $25,000) American LegalNet, Inc. www.FormsWorkflow.com DO NOT FILE WITH THE COURT DISC-010 CASE NUMBER: PLAINTIFF (Name): DEFENDANT (Name): —QUESTIONS— 1. FOR ALL CASES a. State your name and street address. b. State your current business name and street address, the type of business entity, and your title. c. Describe in detail your claims or defenses and the facts on which they are based, giving relevant dates. See attachment for answer number 1c. d. State the name, street address, and telephone number of each person who has knowledge of facts relating to this lawsuit, and specify his or her area of knowledge. See attachment for answer number 1d. e. Describe each document or photograph that relates to the issues or facts. You are encouraged to attach a copy of each. For each that you have described but not attached, state the name, street address, and telephone number of each person who has it. See attachment for answer number 1e. DISC-010 [Rev. January 1, 2007] CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES (Under $25,000) Page 2 of 4 DISC-010 DO NOT FILE WITH THE COURT CASE NUMBER: PLAINTIFF (Name): DEFENDANT (Name): 1. f. Describe each item of physical evidence that relates to the issues and facts; give its location; and state the name, street address, and telephone number of each person who has it. See attachment for answer number 1f. g. State the name and street address of each insurance company and the number of each policy that may cover you in whole or part for the damages claimed. See attachment for answer number 1g. 2. FOR PERSONAL INJURY OR PROPERTY DAMAGE CASES a. Describe each injury or illness that you received and your present complaints about each. See attachment for answer number 2a. b. State the name, street address, and telephone number of each physician, dentist, or other health care provider who treated or examined you; the type of treatment; the dates of treatment; and the charges by each to date. See attachment for answer number 2b. c. Itemize the medical expenses you anticipate in the future. See attachment for answer number 2c. d. Itemize your loss of income to date, give the name and street address of each source, and show how the loss is computed. See attachment for answer number 2d. DISC-010 [Rev. January 1, 2007] CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES (Under $25,000) Page 3 of 4 DISC-010 DO NOT FILE WITH THE COURT CASE NUMBER: PLAINTIFF (Name): DEFENDANT (Name): 2. e. Itemize the loss of income you anticipate in the future, give the name and street address of each source, and show how the loss is computed. See attachment for answer number 2e. f. Itemize your property damage, and state the amount or attach an itemized bill or estimate. See attachment for answer number 2f. 9. Describe each other item of damage or cost that you claim, and state the amount. See attachment for answer number 2g. 3. FOR CASES BASED ON AGREEMENTS a. In addition to your answer to 1e, state all the terms and give the date of any part of the agreement that is not in writing. See attachment for answer number 3a. b. Describe each item of damage or cost you claim, state the amount, and show how it is computed. See attachment for answer number 3b. VERIFICATION I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (TYPE OR PRINT NAME) DISC-010 [Rev. January 1, 2007] (SIGNATURE) CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES (Under $25,000) Page 4 of 4