Interrogatories - Injury Report
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Text in this Example:
1. Do you own any interest in real estate?
if so, as to each such interest, state:
the location of the real estate
the nature of your interest in the real estate
the date you acquired such interest
the amount which you paid to acquire such interest
whether there are any mortgages on such real estate. If there are any such mortgages, as to each mortgage, state:
the identity of the mortgage
the amount of the original mortgage obligation
the outstanding obligations of the mortgage
2. Have you conveyed any interest in any real estate to anyone within the last 12 months?
If so, as to each such conveyance, state:
the description of the real estate
the interest which you conveyed
the identity of the person to whom you conveyed that interest
the consideration which you received
3. Do you hold as mortgagee a mortgage in any real estate?
If so, as to each such mortgage, state:
the date on which you acquired the mortgage
the original principal amount of the mortgage
the outstanding balance due on the mortgage
the identity of the mortgagor
4. Do you own any automobiles, trucks, vessels, aircraft, or other vehicles?
If so, as to each such vehicle, state:
the make, model, and year of the vehicle
the identity of the registered owner of the vehicle
the governmental agency registering the vehicle and the registration number
the location of the vehicle
5. Is anyone indebted to you in amount in excess of $100.00?
if so, as to each such indebtedness, state:
the identity of the individual or entity which is indebted to you
the amount of such indebtedness
the date on which the indebtedness is due
6. Do you have any savings, money market, or checking accounts, or certificates of deposit?
If so, as to each such account or certificate, state:
the identity of the depository institution for the account or certificate of deposit
the title and registered owner or holder of the account or certificate of deposit
the current balance of the account or certificate of deposit
7. Do you have or use any safe deposit box or other similar storage facility?
If so, as to each such facility, state:
the identity of the institution in which you rent, lease, or use such a facility
the box or other identifying number for such facility
the name under which such facility is rented, leased, or used
the contents of such facility
8. Do you own or have any interest in any stocks, bonds, mutual funds, money market funds, or other securities or negotiable instruments?
If so, as to each such interest, state:
a full description of the stock, bond, security, or negotiable instrument
the par or face value of such stock bond, security, or negotiable instrument
the registered and beneficial holders of the stock certificate, bond, security, or negotiable instrument
the dates on which interest or dividends are payable
the maturity date of any bond
the identity of the custodian of any and all documents evidencing the interest
the location of any and all such documents
9. Do you own any jewelry, furniture, office equipment, precious metals or stones, television sets, radios, record players, antiques or collectibles, electrical appliances, power or hand tools, photographic equipment, works of art, furs, musical instrument, rare books or map, collections of coins or stamps, silver or china, or other personality with an individual or collective value exceeding $250.00?
If so, as to each such item, state:
a full and complete description of such item and its present condition
the location of such item
whether or not such item is subject to any security interest
the identity of the holder of any such interest
10. Are you a beneficiary of any trust fund?
If so, as to each trust fund, state:
the nature of the trust
the nature of your interest therein
the identity of each trustee
11. Do you own any patents, inventions, trade names, trade secrets, trademarks, service marks, or copyright?
a full and complete description of each item
the number of any other identifying features of such item
12. Do you own any warehouse receipts, bills of lading, or other documents of title?
the identity of such item
whether or not such item is subject to any such security interest
the identity of the holder of any such security interest
13. Are you the plaintiff in any lawsuit which pending or in which a verdict of judgment has not been satisfied in whole or part?
14. Have you applied for a loan or mortgage within the last three years?
If so, as to each such loan or mortgage application, state:
where you applied for such loan
whether or not you were granted such loan
the amount granted for such loan
what you did with the proceeds of such loan, if any
15. In the last three years, have you acted as co-maker, guarantor, or endorser of any loan? If so, provide full details as to each such loan and your relationship thereto, including the amount of the loan.
16. Have you issued or furnished any financial statements within the last three years?
If so, as to each such financial statement, state:
the identity of such financial statement
to whom such financial statement was issued
17. Are you a party to a contract of any kind?
If so, as to each such contract, state:
the identity of such contract
the nature of such contract
the identity of the person or entity with whom you entered into the contract
18. Does any governmental body owe you any money? If so, provide full and complete details thereof.
19. Have you made any claim under any policy of insurance within the last three years?
If so, as to each such claim, state:
the name of the insurer
the policy number
the facts given rise to such claim
whether or not such claim has been paid
20. Do you own or have interest in any partnerships or limited partnerships?
a full and complete description of the partnership or limited partnership, including but not limited to, its name, purpose, assets, registered address, and the identity of each of its general partners
the identity of the agreement or agreements governing the affairs of the partnership
the nature and extent of the interest
the value of the interest, if any
the name under which the interest is owned or otherwise held by you
21. Do you own or have any interest in any business, corporation, partnership, or joint venture other than those identified in responses to the foregoing interrogatories?
If so, as to each, state:
the identity of the business, corporation, partnership, or joint venture
a full and complete description of you interest in same
22. Do you own or have interest in any asset or item of value individually or collectively worth in excess of $500.00 other than those identified in response to the foregoing interrogatories?
If so, as to each such asset or item, state:
a full and complete description of the asset or item
the nature of your interest in the assets or item
the value of the asset or item
23. Are you unable to pay any of your debts or obligations? If so, provide full and complete details thereof.
Attorney for Plaintiff