NO.

_________________________

PETITIONER: IN THE DISTRICT COURT

JUDICIAL DISTRICT

DEFENDANT:

{COUNTY, STATE}

PERSONAL INJURY SPECIAL DAMAGES LIST

I, , am claiming the following medical costs and loss of

opportunity as damages in this case:

HOSPITALS/CLINICS
Name Date of Latest Bill $

DOCTORS/SPECIALISTS
Name Date of Latest Bill $

DRUGS/THERAPIES
Name Date of Latest Bill $

AUTOMOBILE
Year: Color:
Make: Model:
Insurer: Deductible:
Market Value Before: Market Value After:
 WORK
Company: Position:
Wage/Salary: Days Missed:

OTHER

I swear and attest that the above is true and factual to the best of my knowledge.

Signature Date