(Name, Address Of Party or attorney)
State Bar No: ______
(____) _____ - ________
Attorney for _______ (Or "In Pro Per")
SUPERIOR COURT OF THE STATE OF CALIFORNIA
COUNTY OF SANTA CLARA
[PLAINTIFF(S) NAMES] ) CASE NO: _____________
) COMPLAINT FOR
v. ) NEGLIGENCE
[DEFENDANT(S) NAMES] )
Plaintiff complains and for causes of action alleges as follows:
1. Plaintiff, __________ [name], is an individual and is now, and at all times mentioned in
this complaint was, a resident of __________ County, California.
2. Defendant __________ [store] is now, and at all times mentioned in this complaint was, a
corporation organized and existing under the laws of the State of California, with its place of business in
__________ County, California.
3. Plaintiff does not know the true names of defendants DOES 1 through __, inclusive, and
therefore sues them by those fictitious names. __________ [Optionally, in addition to language in
charging allegations that includes fictitiously named defendants: Plaintiff is informed and believes, and
on the basis of that information and belief alleges, that each of those defendants was in some manner
negligently and proximately responsible for the events and happenings alleged in this complaint and for
plaintiff's injuries and damages.]
4. Plaintiff is informed and believes, and on the basis of that information and belief alleges,
that at all times mentioned in this complaint, defendants were the agents and employees of their
codefendants, and in doing the things alleged in this complaint were acting within the course and scope of
that agency and employment.
5. At all times mentioned in this complaint, defendant __________ [store] and defendants
DOES 1 through 50 owned and operated a __________ [grocery or as the case may be] store known as
__________ [store name], located at __________ [address], __________ [city], __________ County,
California. Defendants invited the general public, including plaintiff, to enter the premises of the
__________ [grocery or as the case may be] store and to purchase various __________ [food or as
the case may be] items from defendants.
6. On __________ [date], at approximately __________ [time], __________ [describe
incident, such as: plaintiff was on the premises of defendants' grocery store for the purpose of purchasing
groceries. After entering the store, plaintiff proceeded to the produce aisle when suddenly and without
warning plaintiff slipped on an unknown substance and fell violently to the floor, causing plaintiff to
sustain the serious injuries and damages described below].
7. Defendants, as owners and operators of a __________ [grocery or as the case may be]
a. Failed to maintain the floor of the __________ [grocery or as the
case may be] store in a reasonably safe condition;
b. Allowed a slippery substance to come into contact with and remain
on the floor of the __________ [grocery or as the case may be] store when
defendant knew, or in the exercise of reasonable care should have known,
that the substance created an unreasonable risk of harm to customers in the
c. Failed to warn plaintiff of the danger presented by the presence of
the slippery substance on the floor;
d. Failed to install a nonslip surface on the floor of the store; and
e. Failed to otherwise exercise due care with respect to the matters
alleged in this complaint.
8. As a direct and proximate result of the negligence of defendants as set forth above,
plaintiff slipped and fell while in the store.
9. As a further direct and proximate result of the negligence of defendants as set forth above,
plaintiff sustained the following serious injuries and damages: __________ [set forth injuries and
damages in detail, including medical expenses, lost wages, pain and suffering, and physical injuries].
WHEREFORE, plaintiff demands judgment against defendants, and each of them, for the
1. General damages according to proof;
2. __________ [Specify special damages, for example: Damages for medical and
related expenses according to proof;
3. Damages for loss of earnings according to proof;]
4. __________ [Specify any other relief sought;]
5. Interest according to law;
6. Costs of this action; and
7. Any other and further relief that the court considers proper.
DATED: _______________ __________________________________________
I, _________________________, am a _____________in the above-entitled action. I have read
the foregoing ___and know the contents thereof. The same is true of my own knowledge, except as to
those matters which are therein alleged on information and belief, and as to those matters, I believe it to
I declare under penalty of perjury that the foregoing is true and correct and that this declaration
was executed at Long Beach, California.
DATED: _________________ ___________________________________