Certificate of Impending Impairment Form
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[Attorney name] [Address] [Telephone number] Attorney for Plaintiff, [name] xxx Court, County of xxx [xxx District] xxxxxx ) No. xxx Plaintiff(s) ) vs. ) CERTIFICATE OF IMPENDING ) IMPAIRMENT xxxxxx ) (CCP Ñ411.35(b)(2)) Defendant(s) ) ___________________________) [Name] declares: 1. I am the attorney for plaintiff, [name], in this action. 2. This action is one for damages arising out of professional negligence. 3. I am unable to obtain a consultation with a(n) [category of professional to be consulted] as required by Code of Civil Procedure section 411.35 before the impairment of this action. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: xxx _________________________ [Typed name] Attorney for xxxxxx
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