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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. :
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

Index No. Calendar No.

DISC-004

:
TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name):

Plaintiff(s) -against-

: : :

JUDICIAL SUBPOENA

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

SHORT TITLE:

: Defendant(s) :
CASE NUMBER:

. . . . . . . . . . . . . . . . . . . --. . . . . . . . . . . . . . . . . . . . . . . . . . . . . FORM.INTERROGATORIES. . LIMITED .CIVIL.CASES .(Economic Litigation)
Asking Party: Answering Party: Set No.:

THE PEOPLE OF THE STATE OF NEW YORK

(b) As a general rule, within 30 days after you are served with TO (a) Interrogatories are written questions prepared by a party to these interrogatories, you must serve your responses on the an action that are sent to any other party in the action to be asking party and serve copies of your responses on all other answered under oath. The interrogatories below are form parties who have appeared. See Code of Civil Procedure interrogatories approved for use in economic litigation. sections 2030.260­2030.270 for details. (b) For time limitations, requirements for service on other (c) Each answer must be as complete and straight-forward as GREETINGS: parties, and other details, see Code of Civil Procedure the information reasonably available to you permits. If an sections 2030.010­2030.410 and the cases construing those interrogatory cannot be answered completely, answer it to sections. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the extent possible. (c) TheseHonorable the form interrogatories do not change existing law the (d) If you doCourt at not have enough personal knowledge to fully , relating toof answer an interrogatory, say so, but make a reasonable and located at County interrogatories, nor do they affect an answering party's right to assert any privilege or make any objection. good faith effort to get the information by asking other in room , on the day of , 20 , at o'clock in the noon, and at any recessed Sec. 2. Instructions to the Asking Party persons or organizations, unless the information is equally or adjourned date, to testify and give evidenceuse aby as witness in available to the asking party.the this action on the part of (a) These interrogatories are designed for optional parties under economic litigation in limited civil cases. See (e) Whenever an interrogatory may be answered by referring to Code of Civil Procedure sections 90 through 100. However, a document, the document may be attached as an exhibit to these interrogatories also may be used in unlimited civil the response and referred to in the response. If the cases. document has more of court and refer to you liable to Your failure to comply with this subpoena is punishable as a contempt than one page,will makethe page and section penalty answer to the interrogatory can be found. (b) There partyrestrictions on discoverysubpoena was issued for a maximumwhere the of $50 and all damages sustained as a the are on whose behalf this for most limited civil cases. These restrictions to comply. limit the number of interrogatories (f) Whenever an address and telephone number for the same result of your failure that may be asked. For details, read Code of Civil person are requested in more than one interrogatory, you Procedure section 94. are required to furnish them in answering only the first interrogatory asking forof the Justices of the (c) Some of these interrogatories are similar to questions in the Witness, Honorable , one that information. Case Questionnaire for Limited Civil Cases (form DISC-010) (g) Court in County, day of , 20 Your answers to these interrogatories must be verified, and may be omitted if the information sought has already dated, and signed. You may wish to use the following form been provided in a completed Case Questionnaire. at the end of your answers: (d) Check the box next to each interrogatory that you want the answering party to answer. Use care in choosing those interrogatories that apply to the case and are within the restrictions discussed above. (e) You may insert your own definition of INCIDENT in Section 4, but only where the action arises from a course of conduct or a series of events occurring over a period of time. (f) The interrogatories in section 116.0, Defendant's Contentions - Personal Injury, should not be used until defendant has had a reasonable opportunity to conduct an investigation or discovery of plaintiff's injuries and damages. (g) Additional interrogatories may be attached, subject to the restrictions discussed above. Sec. 3. Instructions to the Answering Party (a) Subject to the restrictions discussed above, you must answer or provide another appropriate response to each interrogatory that has been checked below.
Form Approved for Optional Use Judicial Council of California DISC-004 [Rev. January 1, 2007]

Sec. 1. Instructions to All Parties

I declare under penalty of perjury under the laws of the State of California sign above foregoing answers are true and (Attorney must that the and type name below) correct.
(DATE) (SIGNATURE)

Attorney(s) for
Sec. 4. Definitions

Words in BOLDFACE CAPITALS in these interrogatories are defined as follows: (Check one of the following): (a)

Office and P.O. Address

Telephone No.: Facsimile No.: E-Mail Address: FORM INTERROGATORIES ­ LIMITED CIVIL CASES Mobile Tel. No.:
(Economic Litigation)

(1) INCIDENT includes the circumstances and events surrounding the alleged accident, injury, or other occurrence or breach of contract giving rise to this action or proceeding.

Page 1 of 4 Code of Civil Procedure, §§ 94, 2030.010-2030.410, 2033.710

American LegalNet, Inc. www.FormsWorkflow.com

DISC-004
(2) INCIDENT means (insert your definition here or on a separate, attached sheet labeled "Sec. 4(a) (2)"): 102.0 General Background Information - Individual 102.1 State your name, any other names by which you have been known, and your ADDRESS. 102.2 State the date and place of your birth. (b) YOU OR ANYONE ACTING ON YOUR BEHALF includes you, your agents, your employees, your insurance companies, their agents, their employees, your attorneys, your accountants, your investigators, and anyone else acting on your behalf. (c) PERSON includes a natural person, firm, association, organization, partnership, business, trust, corporation, or public entity. (d) DOCUMENT means a writing, as defined in Evidence Code section 250, and includes the original or a copy of handwriting, typewriting, printing, photostating, photographing, electronically stored information, and every other means of recording upon any tangible thing and form of communicating or representation, including letters, words, pictures, sounds, or symbols, or combinations of them. (e) HEALTH CARE PROVIDER includes any PERSON referred to in Code of Civil Procedure section 667.7(e)(3). (f) ADDRESS means the street address, including the city, state, and zip code. Sec. 5. Interrogatories The following interrogatories have been approved by the Judicial Council under Code of Civil Procedure section 2033.710: CONTENTS 101.0 Identity of Persons Answering These Interrogatories 102.0 General Background Information - Individual 103.0 General Background Information - Business Entity 104.0 Insurance 105.0 [Reserved] 106.0 Physical, Mental, or Emotional Injuries 107.0 Property Damage 108.0 Loss of Income or Earning Capacity 109.0 Other Damages 110.0 Medical History 111.0 Other Claims and Previous Claims 112.0 Investigation - General 113.0 [Reserved] 114.0 Statutory or Regulatory Violations 115.0 Claims and Defenses 116.0 Defendant's Contentions - Personal Injury 117.0 [Reserved] 120.0 How the Incident Occurred - Motor Vehicle 125.0 [Reserved] 130.0 [Reserved] 135.0 [Reserved] 150.0 Contract 160.0 [Reserved] 170.0 [Reserved] 101.0 Identity of Persons Answering These Interrogatories 101.1 State the name, ADDRESS, telephone number, and relationship to you of each PERSON who prepared or assisted in the preparation of the responses to these interrogatories. (Do not identify anyone who simply typed or reproduced the responses.)
DISC-004 [Rev. January 1, 2007]

102.3 State, as of the time of the INCIDENT, your driver's license number, the state of issuance, the expiration date, and any restrictions. 102.4 State each residence ADDRESS for the last five years and the dates you lived at each ADDRESS. 102.5 State the name, ADDRESS, and telephone number of each employer you have had over the past five years and the dates you worked for each. 102.6 Describe your work for each employer you have had over the past five years. 102.7 State the name and ADDRESS of each academic or vocational school you have attended, beginning with high school, and the dates you attended each. 102.8 If you have ever been convicted of a felony, state, for each, the offense, the date and place of conviction, and the court and case number. 102.9 State the name, ADDRESS, and telephone number of any PERSON for whom you were acting as an agent or employee at the time of the INCIDENT. 102.10 Describe any physical, emotional, or mental disability or condition that you had that may have contributed to the occurrence of the INCIDENT. 102.11 Describe the nature and quantity of any alcoholic beverage, marijuana, or other drug or medication of any kind that you used within 24 hours before the INCIDENT. 103.0 General Background Information - Business Entity 103.1 State your current business name and ADDRESS, type of business entity, and your title. 104.0 Insurance 104.1 State the name and ADDRESS of each insurance company and the policy number and policy limits of each policy that may cover you, in whole or in part, for the damages related to the INCIDENT. 105.0 [Reserved] 106.0 Physical, Mental, or Emotional Injuries 106.1 Describe each injury or illness related to the INCIDENT. 106.2 Describe your present complaints about each injury or illness related to the INCIDENT. 106.3 State the name, ADDRESS, and telephone number of each HEALTH CARE PROVIDER who treated or examined you for each injury or illness related to the INCIDENT and the dates of treatment or examination.

FORM INTERROGATORIES­LIMITED CIVIL CASES (Economic Litigation)

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DISC-004
106.4 State the type of treatment or examination given to you by each HEALTH CARE PROVIDER for each injury or illness related to the INCIDENT. 106.5 State the charges made by each HEALTH CARE PROVIDER for each injury or illness related to the INCIDENT. 106.6 State the nature and cost of each health care service related to the INCIDENT not previously listed (for example, medication, ambulance, nursing, prosthetics). 106.7 State the nature and cost of the health care services you anticipate in the future as a result of the INCIDENT. 106.8 State the name and ADDRESS of each HEALTH CARE PROVIDER who has advised you that you may need future health care services as a result of the INCIDENT. 107.0 Property Damage 107.1 Itemize your property damage and, for each item, state the amount or attach an itemized bill or estimate. 108.0 Loss of Income or Earning Capacity 108.1 State the name and ADDRESS of each employer or other source of the earnings or income you have lost as a result of the INCIDENT. 108.2 Show how you compute the earnings or income you have lost, from each employer or other source, as a result of the INCIDENT. 108.3 State the name and ADDRESS of each employer or other source of the earnings or income you expect to lose in the future as a result of the INCIDENT. 108.4 Show how you compute the earnings or income you expect to lose in the future, from each employer or other source, as the result of the INCIDENT. 109.0 Other Damages 109.1 Describe each other item of damage or cost that you attribute to the INCIDENT, stating the dates of occurrence and the amount. 110.0 Medical History 110.1 Describe and give the date of each complaint or injury, whether occurring before or after INCIDENT, that involved the same part of your body claimed to have been injured in the INCIDENT. 110.2 State the name, ADDRESS, and telephone number of each HEALTH CARE PROVIDER who examined or treated you for each injury or complaint, whether occurring before or after the INCIDENT, that involved the same part of your body claimed to have been injured in the INCIDENT and the dates of examination or treatment.
DISC-004 [Rev. January 1, 2007]

111.0 Other Claims and Previous Claims 111.1 Identify each personal injury claim that YOU OR ANYONE ACTING ON YOUR BEHALF have made within the past ten years and the dates. 111.2 State the case name, court, and case number of each personal injury action or claim filed by YOU OR ANYONE ACTING ON YOUR BEHALF within the past ten years. 112.0 Investigation - General 112.1 State the name, ADDRESS, and telephone number of each individual who has knowledge of facts relating to the INCIDENT, and specify his or her area of knowledge. 112.2 State the name, ADDRESS, and telephone number of each individual who gave a written or recorded statement relating to the INCIDENT and the date of the statement. 112.3 State the name, ADDRESS, and telephone number of each PERSON who has the original or a copy of a written or recorded statement relating to the INCIDENT. 112.4 Identify each document or photograph that describes or depicts any place, object, or individual concerning the INCIDENT or plaintiff's injuries, or attach a copy. (if you do not attach a copy, state the name, ADDRESS, and telephone number of each PERSON who had the original document or photograph or a copy.) 112.5 Identify each other item of physical evidence that shows how the INCIDENT occurred or the nature or extent of plaintiff's injuries, and state the location of each item, and the name, ADDRESS, and telephone number of each PERSON who has it. 113.0 [Reserved] 114.0 Statutory or Regulatory Violations 114.1 If you contend that any PERSON involved in the INCIDENT violated any statute, ordinance, or regulation and that the violation was a cause of the INCIDENT, identify each PERSON and the statute, ordinance, or regulation. 115.0 Claims and Defenses 115.1 State in detail the facts upon which you base your claims that the PERSON asking this interrogatory is responsible for your damages. 115.2 State in detail the facts upon which you base your contention that you are not responsible, in whole or in part, for plaintiff's damages. 115.3 State the name, ADDRESS, and the telephone number of each PERSON, other than the PERSON asking this interrogatory, who is responsible, in whole or in part, for damages claimed in this action.

FORM INTERROGATORIES­LIMITED CIVIL CASES (Economic Litigation)

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DISC-004
116.0 Defendant's Contentions - Personal Injury [See Instruction 2(f)] 116.1 If you contend that any PERSON, other than you or plaintiff, contributed to the occurrence of the INCIDENT or the injuries or damages claimed by plaintiff, state the name, ADDRESS, and telephone number of each individual who has knowledge of the facts upon which you base your contention. 116.2 If you contend that plaintiff was not injured in the INCIDENT, state the name, ADDRESS, and telephone number of each individual who has knowledge of the facts upon which you base your contention. 116.3 If you contend that the injuries or the extent of the injuries claimed by plaintiff were not caused by the INCIDENT, state the name, ADDRESS, and telephone number of each individual who has knowledge of the facts upon which you base your contention. 116.4 If you contend that any of the services furnished by any HEALTH CARE PROVIDER were not related to the INCIDENT, state the name, ADDRESS, and telephone number of each individual who has knowledge of the facts upon which you base your contention. 116.5 If you contend that any of the costs of services furnished by any HEALTH CARE PROVIDER were unreasonable, identify each service that you dispute, the cost, and the HEALTH CARE PROVIDER. 116.6 If you contend that any part of the loss of earnings or income claimed by plaintiff was unreasonable, identify each part of the loss that you dispute and each source of the income or earnings. 116.7 If you contend that any of the property damage claimed by plaintiff was not caused by the INCIDENT, identify each item of property damage that you dispute. 116.8 If you contend that any of the costs of repairing the property damage claimed by plaintiff were unreasonable, identify each cost item that you dispute. 11 6.9 If you contend that, within the last ten years, plaintiff made a claim for personal injuries that are related to the injuries claimed in the INCIDENT, identify each related injury and the date. 116.10 If you contend that, within the past ten years, plaintiff made a claim for personal injuries that are related to the injuries claimed in the INCIDENT, state the name, court, and case number of each action filed. 117.0 [Reserved] 120.0 How the Incident Occurred - Motor Vehicle 120.1 State how the INCIDENT occurred. 120.2 For each vehicle involved in the INCIDENT, state the year, make, model, and license number. 120.3 For each vehicle involved in the INCIDENT, state the name, ADDRESS, and telephone number of the driver.
DISC-004 [Rev. January 1, 2007]

120.4 For each vehicle involved in the INCIDENT, state the name, ADDRESS, and telephone number of each occupant other than the driver. 120.5 For each vehicle involved in the INCIDENT, state the name, ADDRESS, and telephone number of each registered owner. 120.6 For each vehicle involved in the INCIDENT, state the name, ADDRESS, and telephone number of each lessee. 120.7 For each vehicle involved in the INCIDENT, state the name, ADDRESS, and telephone number of each owner other than the registered owner or lien holder. 120.8 For each vehicle involved in the INCIDENT, state the name of each owner who gave permission or consent to the driver to operate the vehicle. 150.0 Contract 150.1 Identify all DOCUMENTS that are part of the agreement and for each state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT. 150.2 State each part of the agreement not in writing, the name, ADDRESS, and telephone number of each PERSON agreeing to that provision, and the date that part of the agreement was made. 150.3 Identify all DOCUMENTS that evidence each part of the agreement not in writing, and for each state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT. 150.4 Identify all DOCUMENTS that are part of each modification to the agreement, and for each state the name ADDRESS, and telephone number of the PERSON who has each DOCUMENT. 150.5 State each modification not in writing, the date, and the name, ADDRESS, and telephone number of the PERSON agreeing to the modification, and the date the modification was made. 150.6 Identify all DOCUMENTS that evidence each modification of the agreement not in writing and for each state the name, ADDRESS, and telephone number of the PERSON who has each DOCUMENT. 150.7 Describe and give the date of every act or omission that you claim is a breach of the agreement. 150.8 Identify each agreement excused and state why performance was excused. 150.9 Identify each agreement terminated by mutual agreement and state why it was terminated, including dates. 150.10 Identify each unenforceable agreement and state the facts upon which your answer is based. 150.11 Identify each ambiguous agreement and state the facts upon which your answer is based.
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FORM INTERROGATORIES­LIMITED CIVIL CASES (Economic Litigation)