Exhibit,Appendix: Amy Leifer v. Jack E Rief, Michael D Leifer -Third Party

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                                INDEX   NO.    034294/2011
(FILED:     ROCKLAND       COUNTY CLERK 0272072014)
NYSCEF   DOC.   NO.   60                              RECEIVED   NYSCEF:    02/20/2014




                                              |
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF ROCKLAND
 AMY LEIFER,

                                 Plaintifi(s).           INDEX #: 034294/2011

                 -against-                              VERDICT SHEET
                                                         (DAMAGES)
 JACK E. RIEF,

                                 Defendant(s).

 JACK E. RIEF,

                             Third-Party Plaintiff,

               -against-

 MICHAEL D. LEIFER,

                             Third-Party Defendant.




       Plaintiff, by her trial counsel, Neimark & Neimark, LLP, respectfully requests that the

verdict form submitted to the jury in this action be as follows:



Dated: New City, New York
       February 20, 2014




                                                 BRENT S. GOLIS.
                                                 NEIMARK & NEI     me    oO
                                                                        ARK Bb
                                                 Attomeys for Plaintiffs)
                                                 AMY LEIFER
                                                 37 Congers Road
                                                 New City, New York 10956-5135
                                                 (845) 638-3012
                                                 Our File No. B-272
TO:
Law Offices of Epstein, Gialleonardo & Rayhill
Attorneys for Defendant(s)
MICHAEL LEIFER
565 Taxter Road, Suite 275
Elmsford, New York 10523
(914) 347-6360
Thomas E. Mehrtens, P.C.
Attorneys for Defendant(s)
JACK E. RIEF
111 Lake Avenue
Tuckahoe, NY 10707
(914) 643-6517
1)     As a result of the accident, has the plaintiff Amy Leifer permanently lost

the use of a body member?

                       Yes                      No

                       Proceed to Question 2.

Signatures of all jurors concurring:




Signature of any juror dissenting:
2)      As a result of the accident, has the plaintiff Amy Leifer sustained an injury which

results in a significant disfigurement?

                        Yes                      No

                        Proceed to Question 3.

Signatures of all jurors concurring:




Signature of any juror dissenting:
3)      As a result of the accident, has the plaintiff Amy Leifer sustained a

significant limitation of use of a body function or system?

                       Yes                      No    ee

                       Proceed to Question 4.

Signatures of all jurors concurring:




Signature of any juror dissenting:
4)      As a result of the accident, has the plaintiff Amy Leifer sustained a

permanent consequential limitation of use of a body organ or member?

                       Yes                      No

                       Proceed to Question 5.

Signatures of all jurors concurring:




Signature of any juror dissenting:
5)      As a result of the accident, did the plaintiff Amy Leifer sustain a medically

determined injury or impairment of a non-permanent nature that prevented her from performing

substantially al! of the material acts that constituted her usual and customary daily activities for

not less than ninety days during the one hundred eighty days immediately following the

accident?

                        Yes                    No

                        If you answered Yes to one or more of the preceding questions proceed to

Question 6. If you answered No to each and every preceding questions proceed no further and

report your verdict to the Court.

Signatures of all jurors concurring:




Signature of any juror dissenting:
6)      State the amount of damages awarded to the plaintiff Amy Leifer for pain

and suffering and loss of enjoyment of life from the date of injury to the date of verdict:

                       $

                       Proceed to Question 7.

Signatures of all jurors concurring:




Signature of any juror dissenting:
7)      State the amount of damages awarded to the plaintiff Amy Leifer for

future pain and suffering and loss of enjoyment of life:

       $

                       If you made an award in answer to Questions 7, proceed to Question 8.



Signatures of all jurors concurring:




Signature of any juror dissenting:
8)      If an award was made in answer to Question 7 above, state the number of

years for which this sum is intended to compensate the plaintiff Amy Leifer:



                       Report your verdict to the Court.

Signatures of all jurors concurring:




Signature of any juror dissenting: