CIV-050 - Statement of Damages (Personal Injury or Wrongful Death)

Summary

Statement of Damages (Personal Injury or Wrongful Death)

Text

Form ID: CIV-050
Title: Statement of Damages (Personal Injury or Wrongful Death)
Effective Date: 2025-07-01
Mandatory Form: yes
Info Page: https://selfhelp.courts.ca.gov/jcc-form/CIV-050
Primary Download URL: https://www.courts.ca.gov/documents/civ050.pdf
Form Detail Page:
Statement of Damages (Personal Injury or Wrongful Death)
(CIV-050)
Tells the other side the maximum amount of damages you are seeking in a personal injury or wrongful death case. It is not filed with the court except when the defendant defaults.
Get form CIV-050
Effective: July 1, 2025
PDF Text:
Form Adopted for Mandatory Use 
Judicial Council of California 
CIV-050 [Rev. July 1, 2025]
STATEMENT OF DAMAGES 
(Personal Injury or Wrongful Death)
Code of Civil Procedure, §§ 425.11, 425.115 
courts.ca.gov
CIV-050- DO NOT FILE WITH THE COURT - 
- UNLESS YOU ARE APPLYING FOR A DEFAULT JUDGMENT UNDER CODE OF CIVIL PROCEDURE § 585 -
FOR COURT USE ONLY
CASE NUMBER:
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address):
TELEPHONE NO.:
      ATTORNEY FOR (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PLAINTIFF:
DEFENDANT:
STATEMENT OF DAMAGES 
(Personal Injury or Wrongful Death)
To (name of one defendant only):
Plaintiff (name of one plaintiff only):
seeks damages in the above-entitled action, as follows:
1. General damages AMOUNT
a. Pain, suffering, and inconvenience  ................................................................................................. $
b. Emotional distress. ........................................................................................................................... $
c. Loss of consortium ........................................................................................................................... $
d. Loss of society and companionship (wrongful death actions only) .................................................. $
e. Other (specify) $
f. Other (specify) $
g. Continued on Attachment 1.g.
2. Special damages
a. Medical expenses (to date) .............................................................................................................. $
b. Future medical expenses (present value) ........................................................................................ $
c. Loss of earnings (to date) ................................................................................................................ $
d. Loss of future earning capacity (present value) ............................................................................... $
e. Property damage ............................................................................................................................. $
f. Funeral expenses (wrongful death actions only) ............................................................................. $
g. Future contributions (present value) (wrongful death actions only) ................................................. $
h. Value of personal service, advice, or training (wrongful death actions only) ................................... $
i. Other (specify) $
j. Other (specify) $
k. Continued on Attachment 2.k.
3. Punitive damages: Plaintiff reserves the right to seek punitive damages in the amount of (specify).. 
when pursuing a judgment in the suit filed against you.
 $
Date:
(TYPE OR PRINT NAME)
 (SIGNATURE OF PLAINTIFF OR ATTORNEY FOR PLAINTIFF)
(Proof of service on reverse) Page 1 of 2

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CIV-050 [Rev. July 1, 2025] PROOF OF SERVICE 
(Statement of Damages) Code of Civil Procedure §§ 425.11, 425.115
CIV-050
PLAINTIFF:
DEFENDANT:
CASE NUMBER:
PROOF OF SERVICE
(After having the other party served as described below, with any of the documents identified in item 1, have the person who served  
the documents complete this Proof of Service. Plaintiff cannot serve these papers.)
1. I served the
a. Statement of Damages Other (specify):
b. on (name):
c. by serving defendant other (name and title or relationship to person served):
d. by delivery at home at business
(1) date:
(2) time:
(3) address:
e. by mailing
(1) date:
(2) place:
2. Manner of service (check proper box):
a. Personal service. By personally delivering copies. (Code Civ. Proc., § 415.10.) 
b. Substituted service on corporation, unincorporated association (including partnership), or public entity. By 
leaving, during usual office hours, copies in the office of the person served with the person who apparently was in charge 
and thereafter mailing (by first-class mail, postage prepaid) copies to the person served at the place where the copies 
were left. (Code Civ. Proc., § 415.20(a).)
c. Substituted service on natural person, minor, conservatee, or candidate. By leaving copies at the dwelling house, 
usual place of abode, or usual place of business of the person served in the presence of a competent member of the 
household or a person apparently in charge of the office or place of business, at least 18 years of age, who was informed 
of the general nature of the papers, and thereafter mailing (by first-class mail, postage prepaid) copies to the  person 
served at the place where the copies were left. (Code Civ. Proc., § 415.20(b).) (Attach separate declaration or affidavit 
stating acts relied on to establish reasonable diligence in first attempting personal service.)
d. Mail and acknowledgment service. By mailing (by first-class mail or airmail, postage prepaid) copies to the person 
served, together with two copies of the form of notice and acknowledgment and a return envelope, postage prepaid, 
addressed to the sender. (Code Civ. Proc., § 415.30.) (Attach completed acknowledgment of receipt.)
e. Certified or registered mail service. By mailing to an address outside California (by first-class mail, postage prepaid, 
requiring a return receipt) copies to the person served. (Code Civ. Proc., § 415.40.) (Attach signed return receipt or 
other evidence of actual delivery to the person served.)
f. Other (specify code section):
additional page is attached.
3. At the time of service I was at least 18 years of age and not a party to this action. 
4. Fee for service: $ 
5. Person serving:
a. California sheriff, marshal, or constable
b. Registered California process server
c. Employee or independent contractor of a registered 
California process server
d. Not a registered California process server 
e. Exempt from registration under Business and 
Professions Code section 22350(b)
f. Name, address, and telephone number and, if applicable, 
county of registration and number:
I declare under penalty of perjury under the laws of the  
State of California that the foregoing is true and correct.
Date:
(SIGNATURE)
(For California sheriff, marshal, or constable use only)  
I certify that the foregoing is true and correct.
Date:
(SIGNATURE)
Page 2 of 2

Retrieval chunks

• #1

  Form ID: CIV-050 Title: Statement of Damages (Personal Injury or Wrongful Death) Effective Date: 2025-07-01 Mandatory Form: yes Info Page: https://selfhelp.courts.ca.gov/jcc-form/CIV-050 Primary Download URL: https://www.courts.ca.gov/documents/civ050.pdf Form Detail Page: Statement of Damages (Personal Injury …

• #2

  d. Loss of future earning capacity (present value) ............................................................................... $ e. Property damage ............................................................................................................................. $ f. Funeral expenses (wrongful death a…

• #3

  usual place of abode, or usual place of business of the person served in the presence of a competent member of the household or a person apparently in charge of the office or place of business, at least 18 years of age, who was informed of the general nature of the papers, and thereafter mailing (by first-class mail…