Superior Court of California County of San Francisco CHECKLIST FOR COURT JUDGMENT ­ PERSONAL INJURY /PROPERTY DAMAGE CASE # :__________________________ All co-defendants, incl. "Does", defaulted/dismissed......................Yes No Amount of principal requested in prayer.......$________________ Less credit...........................................................$________________ Principal awarded ...............................................................................$___________________ Filing fees requested ......................$__________; awarded .....................$______________ Process server requested.................$___________; awarded......................$______________ Is process server Registered or Exempt Other justified costs requested.....$___________; awarded .....................$______________ (list other justified costs)____________________________________________________________________________ Total Costs Awarded.............................................................................$______________ Does Declaration justify higher costs...............................................Yes No Is there a Subrogation declaration from Insurance Company ......Yes No Is there a 585(d) Declaration.............................................................Yes No Defendant informed of amount of bill on................. ____/_____/______ Amount of prejudgment interest requested. (7% X ____principal ÷ 365 X _____days from the date of the demand to the date of judgment) Amount of Prejudgment Interest.......................................................$___________________ Medical expenses requested.........$___________; awarded .....................$_________________ Bills substantiating medical ________________________________________________________________ 2. TOTAL MEDICAL EXPENSES AWARDED............................$_________________ Wage loss requested.......................$__________; awarded ......................$_____________ No. of days on employer's verification......_________days 1. TOTAL WAGE LOSS AWARDED..........................................$_________________ For Court Use Only Date: ______________ Clerk: _________________ CHECKLIST FOR COURT JUDGMENT- PROPERTY DAMAGE/PERSONAL INJURY Page 1 of 2 CK-5 American LegalNet, Inc. www.FormsWorkFlow.com Property damage requested .................$_________________; awarded $ ___________________ Repair bills substantiating property damage_________________________________________________________________ Towing and other charges substantiating charges___________________________________________________________ Loss of use requested............................$_________________; awarded $ _________________ No. of days/hours on repair bill.....______ DAYS/HRS. Total claimed ( add 1+2+3+4+5) ..............................$___________________ Total principal requested...........................................- .$___________________ BALANCE, if any........................................$___________________ 5. 4. TOTAL TOWING AWARDED.........................................$_________________ Towing and other charges requested...$________________; awarded $ __________________ 3. TOTAL PROPERTY DAMAGE AWARDED...................$___________________ Continued.. Case # __________________ TOTAL LOSS OF USE AWARDED...................................$__________________ For Court use Only Date: ______________ Clerk: _____________________ CHECKLIST FOR COURT JUDGMENT- PROPERTY DAMAGE/PERSONAL INJURY Page 2 of 2 CK-5 American LegalNet, Inc. www.FormsWorkFlow.com