IN THE CIRCUIT COURT FOR _____ COUNTY, ALABAMA

X., Administrator of the Estate of A., and Administrator of the Estate of B., both deceased; and C., individually,

Plaintiffs,

vs.

R.,

Defendant.

CIVIL ACTION NO. ______

COMPLAINT

Count One

1. [Identification of Parties]

2. On the ____ day of ____, 19__, A., deceased, B., deceased, and plaintiff, C., were passengers in an automobile which was proceeding in a westerly direction along First Avenue, North, near its intersection with Second Street, in the City of Birmingham, Alabama.

3. At the same time and place the defendant, R., was operating a truck and trailer in a westerly direction along First Avenue, North.

4. The defendant, R., negligently [or wantonly] drove the truck and trailer into the automobile occupied by A., B. and C.

5. As a result, A., suffered serious bodily injuries from which she died.

Wherefore, plaintiff, X., as Administrator of the Estate of A., demands judgment against R., on the first count, in the sum of _______ Dollars and costs.

Count Two

1. Plaintiff, X., realleges paragraphs 1, 2, 3 and 4 of Count One.

2. As a result, B., suffered serious bodily injuries from which she died.

Wherefore, plaintiff, X., as Administrator of the Estate of B., demands judgment against the defendant, R., on Count Two, in the sum of _______ Dollars and costs.

Count Three

1. Plaintiff, C., realleges paragraphs 1, 2, 3 and 4 of Count One of this Complaint.

2. As a result, plaintiff, C., was thrown out of the automobile in which he was riding and had his leg broken and was otherwise injured, was prevented from transacting his business, suffered great pain, both mentally and physically, and incurred expenses for medical attention and hospitalization, in the total sum of ________ Dollars.

Wherefore, plaintiff C., demands judgment against R., in the sum of ________ Dollars and costs.

___________________,

Attorney for Plaintiffs