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.

During all the times herein mentioned defendant owned and operated in interstate commerce a railroad which passed through a tunnel located at _______________________ and known as Tunnel No. ____.

2.

On or about June 1, 1966, defendant was repairing and enlarging the tunnel in order to protect interstate trains and passengers and freight from injury and in order to make the tunnel more conveniently usable for interstate commerce.

3.

In the course of thus repairing and enlarging the tunnel on said day, defendant employed plaintiff as one of its workmen and negligently put plaintiff to work in a portion of the tunnel which defendant had left unprotected and unsupported.

4.

By reason of defendant's negligence in thus putting plaintiff to work in that portion of the tunnel, plaintiff was, while so working pursuant to the defendant's orders, struck and crushed by a rock which fell from the unsupported portion of the tunnel and was (here describe plaintiff's injuries).

5.

Prior to these injuries, plaintiff was a strong, able-bodied man, capable of earning $________ per day. By these injuries he has been made incapable of any gainful activity, has suffered great physical and mental pain, and has incurred expense in the amount of $______ for medicine, medical attendance, and hospitalization.

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

______________ Attorney for plaintiff

______________ Address