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 ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF: DEFENDANT: 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: CASE NUMBER: 1. General damages Pain, suffering, and inconvenience .................................................................................................... $ a. b. c. d. e. f. g. a. b. c. d. e. f. g. h. i. j. k. 3. Emotional distress. ............................................................................................................................. $ Loss of consortium ............................................................................................................................. $ Loss of society and companionship (wrongful death actions only) .................................................... $ AMOUNT Other (specify) .................................................................................................................................. $ Other (specify) .................................................................................................................................. $ Continued on Attachment 1.g. Medical expenses (to date) ................................................................................................................ $ Future medical expenses (present value) .......................................................................................... $ Loss of earnings (to date) ................................................................................................................... $ Loss of future earning capacity (present value) .................................................................................. $ Property damage ................................................................................................................................ $ Funeral expenses (wrongful death actions only) ................................................................................ $ Future contributions (present value) (wrongful death actions only) .................................................... $ Value of personal service, advice, or training (wrongful death actions only) ...................................... $ Other (specify) .................................................................................................................................. $ Other (specify) .................................................................................................................................. $ Continued on Attachment 2.k. 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. 2. Special damages 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] Page 1 of 2 Code of Civil Procedure, §§ 425.11, 425.115 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com STATEMENT OF DAMAGES (Personal Injury or Wrongful Death) CIV-050 PLAINTIFF: DEFENDANT: CASE NUMBER: 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 b. on (name): c. by serving d. defendant at home Other (specify): other (name and title or relationship to person served): at business by delivery (1) date: (2) time: (3) address: by mailing (1) date: (2) place: e. 2. Manner of service (check proper box): a. b. Personal service. By personally delivering copies. (CCP § 415.10) 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)) 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.) 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.) 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.) c. d. e. 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: Employee or independent contractor of a registered c. 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 of California that the foregoing is true and correct. Date: (For California sheriff, marshal, or c