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DO NOT FILE WITH THE COURT
THIS IS NOT AN ANSWER OR RESPONSE TO THE COMPLAINT
DISC-010
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
PLAINTIFF (Name):
DEFENDANT (Name):
CASE NUMBER
CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES
(Under $25,000)
REQUESTING PARTY (Name):
RESPONDING PARTY (Name):
—INSTRUCTIONS—
A. The purpose of the case questionnaire is to help the parties settle their differences without spending a lot
of money. This is accomplished by exchanging information about the case early in the lawsuit. The
exchange of case questionnaires may be started only by a plaintiff (or cross-complainant) in a limited civil
case. The case questionnaire is optional, and if plaintiff (or cross-complainant) exercises the option, only
this form may be used.
B. Instructions for plaintiffs (and cross-complainants)
1. Under Code of Civil Procedure section 93, a plaintiff (or cross-complainant) may serve a completed
case questionnaire and a blank questionnaire with a complaint (or cross-complaint).
2. This is the only way you can require defendants (or cross-defendants) to serve you with a completed
case questionnaire.
C. Instructions for defendants (and cross-defendants)
1. If you have been served with a completed case questionnaire by a plaintiff (or cross-complainant),
then you must fill in the blank case questionnaire. Your completed case questionnaire must be served
on that same plaintiff (or cross-complainant) with your answer to the complaint (or cross-complaint).
2. THIS IS NOT AN ANSWER OR RESPONSE TO THE COMPLAINT.
D. Instructions for all parties
1. ALL QUESTIONS REFER TO THE INCIDENT OR AGREEMENT IN THIS LAWSUIT ONLY.
2. Answer each question. If a question is not applicable, answer “NA.”
3. Your answers are not limited to your personal knowledge, but you are required to furnish information
available to you or to anyone acting on your behalf, whether you are a plaintiff, defendant,
cross-complainant, or cross -defendant.
4. Type or legibly print your answer below each question. If you cannot completely answer a question in
the space provided on the case questionnaire, check the “attachment” box and put the number of the
question and the complete answer on an attached sheet of paper or form MC-025. You should not put
part of an answer on the case questionnaire and part on the attachment. You may put more than one
answer on each attached page.
5. When you have completed the case questionnaire, sign the verification and serve the original.
6. You may compel compliance with these requirements under Code of Civil Procedure section 93.
7. DO NOT FILE THIS CASE QUESTIONNAIRE WITH THE COURT.
Form Adopted for Mandatory Use
Judicial Council of California
DISC-010 [Rev. January 1, 2007]
CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES
(Under $25,000)
Page 1 of 4
Code of Civil Procedure, § 93
www.courtinfo.ca.gov
DO NOT FILE WITH THE COURT
DISC-010
CASE NUMBER:
PLAINTIFF (Name):
DEFENDANT (Name):
1.
FOR ALL CASES
a. State your name and street address.
—QUESTIONS—
b. State your current business name and street address, the type of business entity, and your title.
c. Describe in detail your claims or defenses and the facts on which they are based, giving relevant dates.
See attachment for answer number 1c.
d. State the name, street address, and telephone number of each person who has knowledge of facts relating to this lawsuit, and
specify his or her area of knowledge.
See attachment for answer number 1d.
e. Describe each document or photograph that relates to the issues or facts. You are encouraged to attach a copy of each. For
each that you have described but not attached, state the name, street address, and telephone number of each person who
has it.
See attachment for answer number 1e.
DISC-010 [Rev. January 1, 2007]
Page 2 of 4
CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES
(Under $25,000)
PLAINTIFF (Name):
DEFENDANT (Name):
DO NOT FILE WITH THE COURT
DISC-010
CASE NUMBER:
1. f. Describe each item of physical evidence that relates to the issues and facts; give its location; and state the name, street
address, and telephone number of each person who has it.
See attachment for answer number 1f.
g. State the name and street address of each insurance company and the number of each policy that may cover you in whole or
part for the damages claimed.
See attachment for answer number 1g.
2. FOR PERSONAL INJURY OR PROPERTY DAMAGE CASES
a. Describe each injury or illness that you received and your present complaints about each.
See attachment for answer number 2a.
b. State the name, street address, and telephone number of each physician, dentist, or other health care provider who treated or
examined you; the type of treatment; the dates of treatment; and the charges by each to date.
See attachment for answer number 2b.
c. Itemize the medical expenses you anticipate in the future.
See attachment for answer number 2c.
d. Itemize your loss of income to date, give the name and street address of each source, and show how the loss is computed.
See attachment for answer number 2d.
DISC-010 [Rev. January 1, 2007]
Page 3 of 4
CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES
(Under $25,000)
PLAINTIFF (Name):
DEFENDANT (Name):
DO NOT FILE WITH THE COURT
DISC-010
CASE NUMBER:
2. e. Itemize the loss of income you anticipate in the future, give the name and street address of each source, and show how the loss
is computed.
See attachment for answer number 2e.
f. Itemize your property damage, and state the amount or attach an itemized bill or estimate.
See attachment for answer number 2f.
9. Describe each other item of damage or cost that you claim, and state the amount.
See attachment for answer number 2g.
3. FOR CASES BASED ON AGREEMENTS
a. In addition to your answer to 1e, state all the terms and give the date of any part of the agreement that is not in writing.
See attachment for answer number 3a.
b. Describe each item of damage or cost you claim, state the amount, and show how it is computed.
See attachment for answer number 3b.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
VERIFICATION
(TYPE OR PRINT NAME)
(SIGNATURE)
DISC-010 [Rev. January 1, 2007]
Page 4 of 4
CASE QUESTIONNAIRE—FOR LIMITED CIVIL CASES
(Under $25,000)
