PLD-PI-001 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF: DEFENDANT: DOES 1 TO COMPLAINT--Personal Injury, Property Damage, Wrongful Death AMENDED (Number): Type (check all that apply): MOTOR VEHICLE Property Damage Personal Injury OTHER (specify): Wrongful Death Other Damages (specify): CASE NUMBER: Jurisdiction (check all that apply): ACTION IS A LIMITED CIVIL CASE does not exceed $10,000 Amount demanded 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): alleges causes of action against defendant (name or names): 2. This pleading, including attachments and exhibits, consists of the following number of pages: 3. Each plaintiff named above is a competent adult a. except plaintiff (name): (1) a corporation qualified to do business in California an unincorporated entity (describe): (2) a public entity (describe): (3) (4) a minor an adult for whom a guardian or conservator of the estate or a guardian ad litem has been appointed (a) other (specify): (b) (5) other (specify): b. except plaintiff (name): a corporation qualified to do business in California (1) an unincorporated entity (describe): (2) a public entity (describe): (3) (4) a minor an adult for whom a guardian or conservator of the estate or a guardian ad litem has been appointed (a) other (specify): (b) (5) other (specify): Information about additional plaintiffs who are not competent adults is shown in Attachment 3. Form Approved for Optional Use Judicial Council of California PLD-PI-001 [Rev. January 1, 2007] Page 1 of 3 Code of Civil Procedure, § 425.12 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com COMPLAINT--Personal Injury, Property Damage, Wrongful Death PLD-PI-001 SHORT TITLE: CASE NUMBER: 4. Plaintiff (name): is doing business under the fictitious name (specify): and has complied with the fictitious business name laws. 5. Each defendant named above is a natural person a. except defendant (name): (1) a business organization, form unknown (2) a corporation (3) an unincorporated entity (describe): (4) (5) a public entity (describe): other (specify): c. except defendant (name): a business organization, form unknown (1) a corporation (2) (3) an unincorporated entity (describe): (4) (5) a public entity (describe): other (specify): b. except defendant (name): (1) a business organization, form unknown a corporation (2) (3) an unincorporated entity (describe): (4) (5) a public entity (describe): other (specify): d. except defendant (name): (1) a business organization, form unknown (2) a corporation (3) an unincorporated entity (describe): (4) (5) a public entity (describe): other (specify): 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. b. 7. Doe defendants (specify Doe numbers): _________________________ were the agents or employees of other named defendants and acted within the scope of that agency or employment. Doe defendants (specify Doe numbers):_________________________ are persons whose capacities are unknown to plaintiff. 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. the principal place of business of a defendant corporation or unincorporated association is in its jurisdictional area. b. c. injury to person or damage to personal property occurred in its jurisdictional area. d. other (specify): 9. a. b. Plaintiff is required to comply with a claims statute, and has complied with applicable claims statutes, or is excused from complying because (specify): PLD-PI-001 [Rev. January 1, 2007] COMPLAINT--Personal Injury, Property Damage, Wrongful Death Page 2 of 3 PLD-PI-001 SHORT TITLE: CASE NUMBER: 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 d. Products Liability e. Premises Liability f. Other (specify): 11. Plaintiff has suffered a. wage loss b. loss of use of property c. hospital and medical expenses d. general damage e. property damage f. loss of earning capacity g. other damage (specify): 12. a. b. The damages claimed for wrongful death and the relationships of plaintiff to the deceased are listed in Attachment 12. 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 compensatory damages a. (1) punitive damages (2) The amount of damages is (in cases for personal injury or wrongful death, you must check (1)): according to proof (1) in the amount of: $ (2) 15. The paragraphs of this complaint alleged on information and belief are as follows (specify paragraph numbers): Date: (TYPE OR PRINT NAME) PLD-PI-001 [Rev. January 1, 2007] (SIGNATURE OF PLAINTIFF OR ATTORNEY) COMPLAINT--Personal Injury, Property Damage, Wrongful Death Page 3 of 3