(Rev. 2/28/01) CCM 0071 (This form replaces form CCM1-17) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS MUNICIPAL DISTRICT __________ DISTRICT CIRCUIT COURT PRE-TRIAL MEMORANDUM (The information required in this memo should be full, complete, typewritten and in triplicate before case is called for hearing.) ___________________________________________________ ___________________________________________________ General Number ______________________________________ } Plaintiff requests ____________ $ ______________ Defendant recommends ______ $ ______________ Court recommends __________ $ ______________ Settlement figure ______ $ ______________ Plaintiff's Name: Age: ___________________________________________________ ___________________________________________ Occupation: Married or single: ___________________________________________________ ___________________________________________ Attorney for plaintiff: ___________________________________________________ Attorney for defendant: ___________________________________________ Date, hour and place of accident: ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ Injuries: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Attending physicians: ___________________________________________________ ___________________________________________________ ___________________________________________________ Medical fee(s): ___________________________________________ ___________________________________________ ___________________________________________ Name of hospital: ___________________________________________________ Hospital bill(s): ___________________________________________ Place of employment: ___________________________________________________ Loss of Income(s): ___________________________________________ Miscellaneous out-of-pocket: ___________________________________________________ ___________________________________________ Total liquidated damages: ________________________________________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form