Rev. 6/2017 KSJC 1 [CAPTION] PETITION FOR NEGLIGENCE Plaintiff (name) states the following claim for relief against the defendant, (name) : 1. On or about (date) defendant [describe negligent action of defendant] at ( location), (city ), Kansas. 2. As a direct result of defendants negligence, plaintiff suffered to date (personal injury with accompanying pain and suffering) (physical disability or disfigurement) (mental anguish) (medical expenses) (loss of time) (loss of income) (property damage) [Include any that apply. See K.S.A. 40-3117 for provisions relating to certain damages arising from a motor vehicle accident]. 3. Plaintiff further expects to suffer continuing, future or permanent loss and damages such as [list areas cited above which qualify or any other damages claimed]. 4. Plaintiff claims total damages (in an amount of $ insert dollar figure if $75,000 or less ) (in an amount in excess of $75,000), together with interest, costs of this action and other appropriate relief. (Signature of Attorney) (Name), Attorney for (name of plaintiff) Bar Registration Number Address Telephone number [Facsimile number] [Email address] Authority K.S.A. 60-208; K.S.A. 60-209(h); K.S.A 60-210 American LegalNet, Inc. www.FormsWorkFlow.com