VF-3030. Unruh Civil Rights Act (Civ. Code, §§ 51, 52(a)) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1. Did [name of defendant] [deny/aid or incite a denial of/discriminate or make a distinction that denied] full and equal [accommodations/advantages/facilities/privileges/services] to [name of plaintiff]? ____ Yes ____ No If your answer to question 1 is yes, then answer question 2. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 2. Was [[name of defendant]'s perception of] [name of plaintiff]'s [sex/race/color/religion/ancestry/national origin/medical condition/genetic information/marital status/sexual orientation/citizenship/primary language/immigration status/[insert other actionable characteristic]] a substantial motivating reason for [name of defendant]'s conduct? ____ Yes ____ No If your answer to question 2 is yes, then answer question 3. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 3. Was [name of defendant]'s conduct a substantial factor in causing harm to [name of plaintiff]? ____ Yes ____ No VF-3030. Unruh Civil Rights Act (Civ. Code, §§ 51, 52(a)) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 If your answer to question 3 is yes, then answer question 4. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 4. What are [name of plaintiff]'s damages? [a. Past economic loss [lost earnings [lost profits [medical expenses [other past economic loss Total Past Economic Damages: [b. Future economic loss [lost earnings [lost profits [medical expenses [other future economic loss $ $ $ $ ] ] ] ] ] $ $ $ $ $ ] ] ] ] ] Total Future Economic Damages: $ [c. Past noneconomic loss, including [physical VF-3030. Unruh Civil Rights Act (Civ. Code, §§ 51, 52(a)) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 pain/mental suffering:] [d. Future noneconomic loss, including [physical pain/mental suffering:] TOTAL Answer question 5. 5. Signed: Presiding Juror $ $ $ ] ] What amount, if any, do you award as a penalty against [name of defendant]? $ Dated: After [this verdict form has/all verdict forms have] been signed, notify the [clerk/bailiff/court attendant] that you are ready to present your verdict in the courtroom. _____________________________________________________________________________ New September 2003; Revised April 2007, December 2010, June 2012; Renumbered from CACI No. VF-3010 December 2012; Revised June 2013, December 2016