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The Statement of Damages form is an essential document that plaintiffs in California may need to complete in cases involving personal injury or wrongful death. This form helps outline the specific damages a plaintiff is seeking in a legal action. If you’re considering filing a lawsuit, understanding this form can be tremendously beneficial. It requires the plaintiff to detail various categories of damages, including general damages such as pain and suffering, and special damages like medical expenses and loss of earnings. For wrongful death cases, it allows for the inclusion of elements like loss of consortium and funeral expenses. Another vital aspect of this form is the reserved right to claim punitive damages, which is additional compensation intended to punish the defendant. Importantly, this form should not be filed with the court unless it accompanies a request for default judgment. The process is designed to ensure that the defendant is properly informed of the claims against them, thereby promoting transparency in legal proceedings. Thoroughness and accuracy when filling out the Statement of Damages form are crucial, as it helps set the stage for the legal processes to follow.

Statement Damages Example

 

 

- DO NOT FILE WITH THE COURT-

 

 

 

CIV-050

 

 

 

 

 

 

 

 

-UNLESS YOU ARE APPLYING FOR A DEFAULT JUDGMENT UNDER CODE OF CIVIL PROCEDURE § 585 -

 

 

 

 

 

 

 

 

 

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address):

TELEPHONE NO.:

 

 

 

 

FOR COURT USE ONLY

 

 

 

 

 

 

 

To keep other people from

 

 

 

 

 

 

seeing what you entered on

 

 

 

 

 

 

your form, please press the

 

 

 

 

 

 

Clear This Form button at the

 

ATTORNEY FOR (name):

 

 

end of the form when finished.

 

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

 

 

 

 

 

 

 

STREET ADDRESS:

 

 

 

 

 

 

 

MAILING ADDRESS:

 

 

 

 

 

 

 

CITY AND ZIP CODE:

 

 

 

 

 

 

 

 

BRANCH NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLAINTIFF:

 

 

 

 

 

 

 

DEFENDANT:

 

 

 

 

 

 

 

 

CASE NUMBER:

 

 

 

 

 

 

STATEMENT OF DAMAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Personal Injury or Wrongful Death)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To (name of one defendant only):

 

 

 

 

 

 

 

Plaintiff (name of one plaintiff only):

 

 

 

 

 

 

 

seeks damages in the above-entitled action, as follows:

 

 

 

 

AMOUNT

1. General damages

 

 

 

 

 

 

 

 

 

 

 

a.

 

Pain, suffering, and inconvenience

 

 

$

 

 

 

 

 

 

b.

 

Emotional distress

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

c.

 

Loss of consortium

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

d.

 

Loss of sociey and companionship (wrongful death actions only)

 

 

$

 

 

 

 

 

 

 

 

 

 

 

e.

 

Other (specify)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f.

 

Other (specify)

$

 

 

 

 

 

 

 

 

 

 

g.

 

Continued on Attachment 1.g.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.Special damages

a. b.

c.

d. e.

f. g. h.

i.

j. k.

3.

Medical expenses (to date)

$

Future medical expenses (present value)

$

Loss of earnings (to date)

$

Loss of future earning capacity (present value)

$

Property damage

$

Funeral expenses (wrongful death actions only)

$

Future contributions (present value) (wrongful death actions only)

$

Value of personal service, advice, or training (wrongful death actions only)

$

Other (specify)

$

Other (specify)

$

Continued on Attachment 2.k.

 

Punitive damages: Plaintiff reserves the right to seek punitive damages in the amount of (specify).. $ when pursuing a judgment in the suit filed against you.

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF PLAINTIFF OR ATTORNEY FOR PLAINTIFF)

(Proof of service on reverse)

Page 1 of 2

Form Adopted for Mandatory Use

Judicial Council of California

CIV-050 [Rev. January 1, 2007]

STATEMENT OF DAMAGES

(Personal Injury or Wrongful Death)

Code of Civil Procedure, §§ 425.11, 425.115 www.courtinfo.ca.gov

f. Name, address and telephone number and, if applicable, county of registration and number:
(For California sheriff, marshal, or constable use only) I certify that the foregoing is true and correct.
Date:
(SIGNATURE)

PLAINTIFF:

DEFENDANT:

CIV-050

CASE NUMBER:

PROOF OF SERVICE

(After having the other party served as described below, with any of the documents identified in item 1, have the person who served the documents complete this Proof of Service. Plaintiff cannot serve these papers.)

1.I served the

a. Statement of Damages Other (specify):

b.on (name):

c. by serving

 

defendant

 

other (name and title or relationship to person served):

 

 

d.

 

by delivery

 

at home

 

 

at business

 

 

 

 

(1)date:

(2)time:

(3)address:

e. by mailing

(1)date:

(2)place:

2.Manner of service (check proper box):

a. Personal service. By personally delivering copies. (CCP § 415.10)

b.

 

Substituted service on corporation, unincorporated association (including partnership), or public entity. By

 

 

leaving, during usual office hours, copies in the office of the person served with the person who apparently was in

 

 

charge and thereafter mailing (by first-class mail, postage prepaid) copies to the person served at the place where the

 

 

copies were left. (CCP § 415.20(a))

c. Substituted service on natural person, minor, conservatee, or candidate. By leaving copies at the dwelling house, usual place of abode, or usual place of business of the person served in the presence of a competent member of the household or a person apparently in charge of the office or place of business, at least 18 years of age, who was informed of the general nature of the papers, and thereafter mailing (by first-class mail, postage prepaid) copies to the person served at the place where the copies were left. (CCP § 415.20(b)) (Attach separate declaration or affidavit stating acts relied on to establish reasonable diligence in first attempting personal service.)

d.

e.

Mail and acknowledgment service. By mailing (by first- class mail or airmail, postage prepaid) copies to the person served, together with two copies of the form of notice and acknowledgment and a return envelope, postage prepaid, addressed to the sender. (CCP § 415.30) (Attach completed acknowledgment of receipt.)

Certified or registered mail service. By mailing to an address outside California (by first-class mail, postage prepaid, requiring a return receipt) copies to the person served. (CCP § 415.40) (Attach signed return receipt or other evidence of actual delivery to the person served.)

f. Other (specify code section):

additional page is attached.

3.At the time of service I was at least 18 years of age and not a party to this action.

4.Fee for service: $

5.Person serving:

a.

 

California sheriff, marshal, or constable

 

b.

 

Registered California process server

 

 

Employee or independent contractor of a registered

c.

 

 

 

California process server

d.

 

Not a registered California process server

 

 

 

e.

 

Exempt from registration under Bus. & Prof. Code

 

 

§ 22350(b)

I declare under penalty of perjury under the laws of the

State of California that the foregoing is true and correct.

Date:

(SIGNATURE)

CIV-050 [Rev. January 1, 2007]

PROOF OF SERVICE

 

 

(Statement of Damages)

 

 

 

For your protection and privacy, please press the Clear This Form

 

 

 

Save This Form

button after you have printed the form.

 

 

 

 

 

 

Page 2 of 2

Code of Civil Procedure §§ 425.11, 425.115

Print This Form Clear This Form

Get Statement Damages PDF Form

Form Characteristics

Fact Name Details
Form Title Statement of Damages (Personal Injury or Wrongful Death)
Governing Laws Code of Civil Procedure, §§ 425.11, 425.115 (California)
Purpose This form is used to outline the damages a plaintiff seeks in cases of personal injury or wrongful death.
Filing Instructions The form should not be filed with the court unless applying for a default judgment under § 585.
Eligible Parties Only one plaintiff and one defendant can be listed on the form.
Damage Categories Includes general and special damages, along with medical expenses and potential punitive damages.
Confidentiality Users are advised to clear the form after completing it to protect their information.
Proof of Service A section at the end of the form is dedicated to confirming that the other party has been served.

Guidelines on Utilizing Statement Damages

After completing the Statement of Damages form, ensure it is not filed with the court unless you are applying for a default judgment under specific California law. This document provides a detailed account of the damages sought in a personal injury or wrongful death case. Follow the steps outlined below to accurately fill out the form.

  1. Header Information: Enter your name and address in the section labeled "Attorney or Party Without Attorney." Include your telephone number and the name of the attorney (if applicable).
  2. Case Information: Fill in the "Superior Court of California, County of" section with the street address, mailing address, city, and zip code. Next, list the plaintiff and defendant names and the case number.
  3. Defendant Information: Specify the name of one defendant only in the designated area.
  4. Plaintiff Information: Enter the name of one plaintiff in the appropriate space.
  5. General Damages: In the section labeled "General damages," clearly outline the types of damages being claimed, including pain and suffering, emotional distress, and loss of consortium. Write the respective amounts next to each type of damage, adding additional information as needed.
  6. Special Damages: Provide a detailed account of special damages incurred, including medical expenses, loss of earnings, property damage, and funeral expenses (if applicable). List each item and its corresponding amount.
  7. Punitive Damages: If applicable, indicate if you intend to seek punitive damages by specifying an amount.
  8. Date and Signature: Include the date in the designated area. Print your name, and sign directly beneath that section to confirm the information is accurate.
  9. Proof of Service: This section must be completed after the documents are served to the other party. Specify what documents were served, the date and manner of service, and the person who served them.
  10. Final Checks: Once completed, review the form for accuracy. Press the "Clear This Form" button to protect your information.

What You Should Know About This Form

What is the Statement of Damages form used for?

The Statement of Damages form is a legal document utilized in personal injury or wrongful death cases. It outlines the damages that the plaintiff seeks from the defendant. This form allows the plaintiff to specify both general damages, such as pain and suffering, and special damages, like medical expenses and loss of earnings. It is an essential part of the litigation process, particularly when a plaintiff needs to present their claim for compensation in a clear and organized manner.

When should I submit the Statement of Damages form?

This form is not meant to be filed with the court unless the plaintiff is applying for a default judgment. If the plaintiff is pursuing a default judgment under California's Code of Civil Procedure, it becomes necessary to file the form. In standard scenarios, it is primarily used for communication purposes between the parties involved rather than as a document to be submitted for court records.

How do I fill out the Statement of Damages form?

Filling out the Statement of Damages form requires careful attention to detail. The plaintiff must enter their name, the name of the defendant, the case number, and the specific damages being sought. It's essential to classify the damages correctly into general and special categories and to list precise monetary amounts where applicable. Additionally, when relevant, the plaintiff may include punitive damages. Clear and accurate documentation helps to articulate the extent of the claim effectively.

What if I need to add more information than the form allows?

If the Statement of Damages form does not provide enough space for all the necessary information, a plaintiff can attach additional pages. It is advisable to label these attachments clearly, as seen with “Attachment 1.g” for general damages and “Attachment 2.k” for special damages. This practice ensures that all relevant details regarding the claim are available for review without confusion or ambiguity.

What should I do after completing the Statement of Damages form?

After completing the Statement of Damages form, it is crucial to ensure that it is not filed with the court unless applying for a default judgment. Instead, the completed form should be served to the defendant or their attorney. Proof of service documentation must also be filled out to confirm that the other party has received the form correctly. Finally, it is advisable to safeguard the information by clearing the form once it is printed, as indicated within the form instructions for privacy protection.

Common mistakes

Filling out the Statement of Damages form is an important step in seeking justice after an injury or wrongful death. However, many individuals stumble at this critical juncture. Understanding common mistakes can help ensure that your claims are presented clearly and accurately.

One frequent error occurs when people forget to specify the correct amounts for damages. It’s crucial to provide clear figures for each category—such as general and special damages—because vague estimates can weaken your case. Ensure that every section reflecting your pain and suffering, medical expenses, or lost earnings is filled accurately. Incomplete forms can lead to delays, or worse, the dismissal of your claims.

Many also make the mistake of not tailoring the details of the form to their unique situation. Generic descriptions don’t convey the true extent of your experience or pain. Personalize your responses to reflect your specific circumstances. For instance, when detailing emotional distress, provide examples of how your life has changed since the incident. The more personalized and specific your narrative, the stronger your case becomes.

Another misstep is failing to account for future damages. While it’s easy to focus on current expenses, future medical costs or loss of earning capacity are equally important in establishing the full scope of your losses. Make sure to assess and include your best estimates for these future needs. This thoroughness can significantly impact the outcome of your claim.

Moreover, individuals often overlook the necessity of proof of service. It’s essential to demonstrate how and when the form was delivered to the concerned parties. Missing this step can complicate the proceedings and raise questions about whether all parties have been properly notified. Ensure that you complete this section accurately and retain copies for your records.

Lastly, many people neglect to give proper attention to the signature section. Failing to sign the form—or not including the signature of an attorney if represented—can render the document invalid. A signed form indicates that you acknowledge the information provided is true and correct. Always double-check that your signature is included before submitting the documentation.

By avoiding these common pitfalls, you’ll increase the chances of successfully articulating your damages and advancing your case. Attention to detail in this process is not just beneficial; it can be crucial. Take the time to ensure that your Statement of Damages form reflects your true circumstances. Every detail matters.

Documents used along the form

The Statement of Damages form is essential in personal injury or wrongful death cases. Accompanying documents help to fully articulate the claims, providing detailed information on the damages sought. Here is a list of other documents often used together with the Statement of Damages:

  • Complaint: This document initiates a lawsuit. It outlines the plaintiff’s allegations against the defendant, including the basis for the court's jurisdiction and the relief sought.
  • Summons: This is a legal notice to the defendant to appear in court. It informs them of the lawsuit and the timeframe within which they must respond.
  • Proof of Service: A declaration that shows the defendant has been formally served with court documents. This ensures that the court can proceed with the case.
  • Interrogatories: These are written questions sent by one party to another, which must be answered as part of the discovery process. They help gather detailed information relevant to the case.
  • Request for Production of Documents: This form requests specific documents from the opposing party. It is a crucial discovery tool that enables parties to obtain evidence.
  • Demand for Admissions: This document requests that the opposing party admit or deny specific statements. It streamlines the trial by clarifying which facts are agreed upon.
  • Subpoena: A legal document that requires a witness to appear in court or produce evidence. It is often essential for gathering testimony or materials that support the claims.
  • Settlement Agreement: If parties agree on a resolution prior to trial, this document formalizes the terms of the settlement, ensuring that both parties understand their obligations.

These documents collectively enhance the case presentation. They serve to clarify the issues at hand and facilitate communication between involved parties. Organizing these forms properly contributes to a more efficient legal process.

Similar forms

The Statement of Damages form is an essential document in personal injury and wrongful death cases. Its structure and content are somewhat similar to a few other legal documents that serve different purposes yet follow a comparable format. Here are five such documents, with an explanation of how they relate to the Statement of Damages:

  • Diverse Complaint Forms: These forms outline the claims made by a plaintiff in a lawsuit. Like the Statement of Damages, they specify the type of damages sought and the grounds for the claim, providing a clear breakdown of the alleged injuries and losses.
  • Demand Letters: A demand letter details the amount of compensation requested before a lawsuit is filed. Similar to the Statement of Damages, it articulates specific damages sought, including general and special damages, and conveys the plaintiff's intentions in pursuing financial recovery.
  • Settlement Agreements: Settlement agreements resolve disputes and outline the terms agreed upon by the parties. These documents often summarize the damages claimed, mirroring the way the Statement of Damages lists various types of damages in a structured manner.
  • Medical Expense Statements: These documents provide an itemized list of medical costs incurred by a plaintiff as a result of an incident. In the same way that the Statement of Damages quantifies medical expenses, these statements serve to directly support the claims for special damages in legal proceedings.
  • Affidavit of Support: This document confirms support provided to an injured party. Much like the Statement of Damages, it details specific contributions made and may outline the projected future needs of the plaintiff, ultimately serving to emphasize the extent of damages sought.

Dos and Don'ts

Things to Do When Filling Out the Statement of Damages Form:

  • Complete all required fields with accurate and honest information.
  • Attach any relevant documentation that supports the claims made in the form.
  • Keep a copy of the filled-out form for your records.
  • Only include the appropriate defendant's name in the provided section.
  • Press the "Clear This Form" button after printing to ensure privacy.

Things to Avoid When Filling Out the Statement of Damages Form:

  • Do not file the form with the court unless specifically applying for a default judgment.
  • Avoid using legal jargon or overly complex language that may confuse the reader.
  • Do not leave any required sections incomplete.
  • Refrain from sharing personal information publicly, even in attachments.
  • Do not sign the form without reviewing all the information for accuracy.

Misconceptions

  • It's required to file the Statement of Damages with the court. Many believe that this form needs to be filed. In reality, you only submit this form if you’re applying for a default judgment.
  • The Statement of Damages is only for personal injury cases. While it is commonly used for personal injury, it can also apply to wrongful death cases. Understanding this wider application can help you utilize the form appropriately.
  • You can't change the amounts listed on the form once submitted. This is a common misconception. You can amend the amounts if new information arises or if damages have not been accurately calculated initially.
  • Only attorneys can file the Statement of Damages. While it's true that attorneys can submit the form, plaintiffs can do so themselves as well. Knowing this can empower individuals to take charge of their cases.
  • The form guarantees that you will receive the damages listed. This is not the case. The Statement of Damages is merely an outline of what you seek. The court will ultimately decide the actual award based on evidence presented.
  • Filing this form means your case will go to trial. Many believe that just because they file this form, a trial is inevitable. However, this form can also serve as a starting point for negotiations and settlements.
  • It’s possible to seek punitive damages without specifying them. If you intend to request punitive damages, you must clearly indicate the amount on the form. Failing to do so can limit your claims later.

Key takeaways

When filling out and using the Statement of Damages form, keep these key points in mind:

  • Do not file the form with the court unless you are seeking a default judgment under California Code of Civil Procedure § 585.
  • The form must be completed accurately for one plaintiff and one defendant only.
  • Make sure to specify the amounts for general damages, special damages, and medical expenses clearly.
  • Emotional distress and loss of consortium are important components of general damages.
  • For wrongful death cases, include details for loss of society and companionship in your damages.
  • Do not forget to indicate the amount for punitive damages if you wish to pursue them.
  • After filling out the form, press the Clear This Form button to protect your privacy before saving or printing.
  • Ensure proper service of the Statement of Damages; it cannot be served by the plaintiff.
  • Accurate proof of service is critical, so follow the instructions for completing the service section carefully.

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