Free $$WRK2$$ - Illinois

(This form replaces form CCM1-17)

(Rev. 2/28/01) CCM 0071 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS MUNICIPAL DISTRICT __________ DISTRICT CIRCUIT COURT PRE-TRIAL MEMORANDUM
(The information required in this memo should be full, complete, typewritten and in triplicate before case is called for hearing.)

___________________________________________________ ___________________________________________________ General Number ______________________________________ Plaintiff's Name:

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Plaintiff requests ____________ $ ______________ Defendant recommends ______ $ ______________ Court recommends __________ $ ______________ Settlement figure ______ Age: $ ______________

___________________________________________________
Occupation:

___________________________________________
Married or single:

___________________________________________________
Attorney for plaintiff:

___________________________________________ Attorney for defendant: ___________________________________________ Injuries: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Medical fee(s): ___________________________________________ ___________________________________________ ___________________________________________ Hospital bill(s): ___________________________________________ Loss of Income(s): ___________________________________________

___________________________________________________ Date, hour and place of accident: ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ Attending physicians: ___________________________________________________ ___________________________________________________ ___________________________________________________ Name of hospital: ___________________________________________________ Place of employment: ___________________________________________________ Miscellaneous out-of-pocket: ___________________________________________________

___________________________________________

Total liquidated damages: ________________________________________________________________________
DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS