Circuit Court Forms

FORM 6A(ii)

PERSONAL INJURIES COUNTERCLAIM

O. 5A, r. 5

INDORSEMENT OF COUNTERCLAIM

The defendant counterclaims for the reliefs set out herein for personal injuries suffered by the defendant as follows:

WRONG ALLEGED AGAINST THE PLAINTIFF (OR AGAINST EACH PLAINTIFF)

1 …….

2 …….

PARTICULARS OF THE ACTS OF THE PLAINTIFF (OR OF EACH PLAINTIFF) CONSTITUTING THE WRONG

(Full particulars should be set out)

PARTICULARS OF CIRCUMSTANCES RELATING TO THE COMMISSION OF THE WRONG

(Full particulars should be set out)

PARTICULARS OF EACH INSTANCE OF NEGLIGENCE BY THE PLAINTIFF (OR BY EACH PLAINTIFF)

(Full particulars should be set out)

PARTICULARS OF THE INJURIES TO THE DEFENDANT OCCASIONED BY THE WRONG OF THE PLAINTIFF (OR OF EACH PLAINTIFF)

RELIEFS CLAIMED BY THE DEFENDANT

SCHEDULE

FULL PARTICULARS OF ITEMS OF SPECIAL DAMAGE CLAIMED BY THE DEFENDANT

(Full particulars should be set out. Add additional sheets if necessary)

(If applicable, insert particulars required by Order 5, rule 5A)

This defendant's personal details are as follows:

1. Address of defendant's ordinary residence:

(state address accurately)

2. Defendant's occupation:

3. Defendant's date of birth: Day: .... Month .... Year

4. Defendant's Personal Public Service Number:

5. The defendant's address for service, if different from the address mentioned above, should be stated here:

(Signed)______________________