IN THE ________ COURT OF ________ COUNTY STATE OF GEORGIA

A.B., ) Plaintiff ) ) v. ) Civil action ) File no. ______ C.D., ) (Clerk will insert Defendant ) number.)

COMPLAINT

The defendant C.D., herein named, is a resident of _____________________ (street), ________ (city), ________ County, Georgia, and is subject to the jurisdiction of this court.

1.

On June 1, 1966, on a public highway called Broad Street in Athens, Georgia, defendant negligently drove a motor vehicle against plaintiff who was then crossing said highway.

2.

As a result plaintiff was thrown down and had his leg broken and was otherwise injured, was prevented from transacting his business, suffered great pain of body and mind, and incurred expenses for medical attention and hospitalization in the sum of $1,000.00.

Wherefore, plaintiff demands judgment against defendant in the sum of $10,000.00 and costs.

______________ Attorney for plaintiff

______________ Address