Law Offices of Craig Zimmerman

P.O. Box 15126

Santa Ana CA 92735

(800)987-3066 ext: 4504 (714)933-4604 (fax) mguzman@craigzlaw.com

CLIENT QUESTIONNAIRE
Thank you for taking the time necessary to carefully answer this questionnaire. It is
essential that I obtain all of the information asked about in the following questions so
that I can properly evaluate your claim. For most of the questions, space has been
provided on this form for your answers. For several of the questions, it will be necessary
to write your answers on separate pages. Please use ink and write or print legibly or use
a typewriter or word processor if possible. As you can see, this is a standardized
questionnaire for all my clients. If any of the questions are inapplicable to you, please
cross out the question so I will know that it is inapplicable. Once the questionnaire is
completed, return it and all of the requested attachments to my mailing address listed
above.

Information About You

Full Legal Name: Kabine Coulibaly

Name You Prefer To Be Called By:

Date of Birth: 11/09/1989 Social Security No.: 364-37-6593

10020 Pineshadow Drive apt 109
Mailing Address:

Charlotte, North Carolina 28262

County: United States

Telephone: Home: Work:

Home Fax: Work Fax:

eMail: Kabicouli@gmail.com Pager:

Mobile: 517-290-1258

Client Questionnaire, page 1

 Management Trainee
Your Occupation, Employer, and Place of Employment:
at enterprise in Concord,North Carolina

Work Hours: 7 AM- 6:40 PM

Call
Can I Call or Fax You at Work?

If So, Any Special Instructions?

Highest Grade/Degree Completed:

Trade or Professional Licenses Held:

Information About Your Family

Spouses Legal Name:

Name To Be Called By:

Date of Birth: Social Security No.:

Telephone: Home: Work:

Home Fax: Work Fax:

eMail: Pager:

Mobile:

Occupation, Employer, and Place of Employment:

Work Hours:

Can I Call or Fax at Work?

If so, Any Special Instructions?

Highest Grade/Degree Completed:

Client Questionnaire, page 2

Trade or Professional Licenses Held:

Childrens Names and Dates of Birth:

Other Attorneys

If you have talked to another attorney about your claim, please answer the following
questions in this section. If you have talked to more than one other attorney, please
answer the questions for each attorney. You may need to use a separate piece of paper if
that is the case.

What is the name, address, and telephone number of the attorney to whom you have
spoken about this claim?

Name:

Firm:

Address:

City: State: Zip:

Was any agreement made with this attorney?

If you have a copy of a written agreement, please attach it to this questionnaire.

If yes, is the agreement still in effect?

If the agreement is not still in effect, why not?

Have you or do you expect to pay the attorney for any fees or expenses?

Client Questionnaire, page 3

 Prior Legal Involvement

Have you or your spouse been involved in prior civil lawsuits, arrested, or charged with
a crime?
If yes, please list on a separate page all prior lawsuits or criminal matters in which you
have been involved and include the following information for each:

1. The names of the parties to the lawsuit

2. The type of the case
3. The outcome of the case
4. The name of your attorney in the case

Nature Of Your Claim

In a few sentences, please describe the type of claim that you have:

Client Questionnaire, page 4

 Insurance

Some claims, particularly those for property damage, personal injury or medical
expenses may be covered at least partially by insurance. The policy may belong to you,
or it may belong to one of the parties you want to sue. Many businesses carry general
liability policies that cover more than just personal injury and property damage claims.
If you know of an insurance policy that may cover some or all of your claim, please
provide the following information:

Name of Insured:

Insurance company:

Type of policy:

Effective date(s) of policy:

Has a claim been filed?

If so, what is the claim number:

Who is the adjuster handling the claim?

Name:

Telephone Number:

Please attach a copy of the policy and any claim documents to this questionnaire.

Witness Statements

Have you or anyone you know given a formal or informal statement concerning this T
claim? A formal statement may be a written statement of facts signed by you or a tape-
recorded statement acknowledged by you to be true and correct. Formal statements are
usually taken by claims adjusters or investigators. An informal statement may be any
conversation you have with a claims adjuster or investigator or other interested party
concerning the claim. If so, state the following:

When was the statement given? Was the statement formal or informal?

Who took the statement?

On whose behalf was the statement taken?

Who gave the statement?

Client Questionnaire, page 5

 Opposing Parties

Please list the full name, address (with zip code) and telephone number of every person
against whom you believe you have a claim that I should pursue. Include in your list a
brief statement as to why you believe you have a claim against each person. If you need
to include additional persons, you can use a separate sheet of paper or make a copy of
this page.

Name: Jim Gilbert (Rusel Felts Motors Co)

Address: 15505 Capital Port

City: San Antonio State: TX Zip Code: 78249

Telephone Number: 210-548-8325

Why you have a claim against this person? he is the agent I dealt with when I
purchased the vehicle.

Name: Joey

Address: 15505 Capital port

City: San Antonio State: TX Zip Code: 78249

Telephone Number: 210-408-1110

Why you have a claim against this person: He is the one who prepare all the paper and I signed the
all papers in his office.

(Make copies of this page if there are more than 2 potential opposing parties)

Client Questionnaire, page 6

 Fact Witnesses

Please list the full name, address (with zip code) and telephone number of every person
who has any knowledge or information about your claim or any of the damages you have
suffered, regardless of how little or how much the person knows, and describe briefly the
facts known to each person. Be sure to include both persons who would testify for you as
well as against you. If you need to include additional persons, you can use a separate
sheet of paper or make a copy of this page.

Name:

Address:

City: State: Zip Code:

Telephone Number:

What does this person know about your claim or damages? Is this witness friendly or
hostile?

Name:

Address:

City: State: Zip Code:

Telephone Number:

What does this person know about your claim or damages? Is this witness friendly or
hostile?

Client Questionnaire, page 7

Name:

Address:

City: State: Zip Code:

Telephone Number:

What does this person know about your claim or damages? Is this witness friendly or
hostile?

Name:

Address:

City: State: Zip Code:

Telephone Number:

What does this person know about your claim or damages? Is this witness friendly or
hostile?

(Make copies of this page if there are more than four witnesses)

Client Questionnaire, page 8

 Expert Witnesses

Expert witnesses are persons with special expertise who you have consulted about your
claim. An expert witness might be a person such as an accountant or a mechanic who
can investigate or explain a complicated aspect of your claim. Please list the full name,
address and telephone number of any and all experts to whom you have talked about
your claim regardless of whether you hired the expert or the expert was hired by
someone else. For each person, write the persons area of expertise and the information
that you believe the expert can provide about your claim. If the expert has produced any
kind of written report, attach it to this questionnaire.

Expert Witness 1

Name: Jenifer Flake Sevice Consltant at Audi Northlake

Address: 10831 northlake Auto Plaza Blvd

City: Charlotte State: NC Zip Code: 28269

Telephone Number: 704-379-8317

What is this persons area of expertise? Service Consultant

What does this person know about your claim or damages? Is this witness friendly or
hostile? She is the Consultant Looked at the car and discovered she is friendly.

Has this person produced a written report? Yes she did it is in the first I got from the dealership
If so, please attach it to this questionnaire.

Client Questionnaire, page 9

 Damages

The amounts and types of damages you will be allowed to seek to recover because of
your claims are determined by the applicable law. At this point however, I need to know
from you all of the losses you feel you have suffered as a result of your claim, whether or
not the law will allow you to seek those damages.

To assist you in answering the questions on damages, I have provided some categories.
If you feel that you have suffered losses that are not covered by the categories, please list
those items and amounts under Other Losses Suffered.

List each loss you have suffered, describing (1) what the loss is and (2) the amount of the
loss, if the loss was caused, in whole or in part, by the conduct of the opposing party or
parties.

1. Out of Pocket Expenses. List money actually paid out by you because of the
unlawful conduct:

Item/Description Amount
Inspection, Water Pump, Coolant Valve 02/01$ 2178.52

Oil Leak, Engine Mount 02/20 $ 980.00

2. Damage Estimate. List here the amount of money it will cost to repair the defects
or conditions resulting from your claim:

Item/Description Amount
Tires $ 1,120

Alignment $ 190

Client Questionnaire, page 10

3. Mental Anguish. Under certain circumstances, you are allowed to recover money
damages if you have suffered mentally or emotionally because of the conduct involved in
your claim. These types of damages are more difficult than most to recover and so you
need to provide as much detailed information as possible. The courts have held that the
duration, intensity, and physical manifestations, if any, of the mental anguish are key
factors for determining whether these damages will be allowed.

a) Have you or your spouse been examined or treated by a physician, psychologist,

or other health care professional for depression, anxiety, or other psychological
symptoms which were caused, in part, by the conduct of the opposing party? If
so, list the time period of the examination or treatment and the name, address
and telephone number of the health care professional(s) who provided the
examination or treatment. Provide any records you have concerning this
treatment.

b) Are you or your spouse now taking or have you taken in the past any kind of
medication for the treatment or control of the psychological symptoms? If so,
what is the name of the medication and the time period during which it was
taken.

c) Regardless of whether you or your spouse have been treated or examined by a

health care professional, have you experienced any of the following symptoms
which you think are or were caused by the conduct of the opposing party(ies):

Change in sleep patterns (sleep more, sleep less)

Change in eating habits (eat more, eat less)

Frequent feelings of depression, inadequacy or failure

Change in relationship with spouse or children

(irritable, less intimacy, etc.)

Client Questionnaire, page 11

 Change in ability to concentrate on daily routine

Other changes in behavior (please specify):

d) During what time period have you experienced these symptoms?

e) Describe the intensity of these symptoms and how they have impacted your daily
life.

4. Personal Injury/Medical Expenses. If you have sought medical attention for any
injury suffered as a result of the conduct of the opposing parties, describe the injury and
include copies of any medical records you have relating to the injury.

5. Other Losses Suffered. Please describe any other financial losses you have
suffered that you believe were caused, in whole or in part, by the conduct of the
opposing party(ies). If, for example, you lost property by foreclosure, describe the
property lost (address, legal description if available), the circumstances of the loss, and
the amount of equity you had in the property at the time of the foreclosure.

6. Special Orders. In most cases, the legal remedy for a violation of the law is money
damages. However, in some cases, it is possible to obtain an order from the court
requiring the opposing party to do or not do something, or transferring ownership of a
particular piece of property. If you would like such an order, describe what order you
want.

Client Questionnaire, page 12

 Diary of Events and Supporting Documents

This is the last question, but it is the most time consuming of all and quite possibly the
most important of all.

Beginning with the first event or conversation that you recall about your case, write a
detailed account of each thing that has happened and each thing that has been said or
done to you and each thing that has been said or done by you. Include dates as best as
you can remember. If you cannot recall an exact date, estimate when the event or
conversation occurred. If you remember the exact words of conversations, use them. If
you do not recall the exact words used, then write out the substance of the words
spoken. Give special attention to your dealings with the other side. The more detailed
your diary is, the better.

Be sure to include in your diary every statement, act, or failure to act of the other side
that you feel caused you harm or damages.

Please write legibly. Use as many pages as necessary.

Attach to your diary as many supporting documents as you can. It is most important to
attach copies of contracts or agreements, sales materials such as brochures, receipts for
purchases, and correspondence with the other side and witnesses.

Client Questionnaire, page 13

 Attachments Checklist

Dont forget to include these documents with your questionnaire. You probably wont
have all of these, but this list should help you to put together as complete a response as
possible.

Agreements with other attorneys

Information about prior lawsuits

Witness statements

Information about additional parties or witnesses

Reports of expert witnesses

Sales materials such as brochures

Contracts and agreements

Receipts for purchases/repairs

Correspondence with the other side and with witnesses

Insurance policies and any documents relating to an insurance claim

Medical records pertaining to claims for personal injury or mental anguish

For now, just include copies. Keep the originals in a safe place where you can find them
if they are needed later. It is not necessary to physically attach the documents. You may
include them in an envelope or file folder with the questionnaire.

Client Questionnaire, page 14