Statement Of Claim And Summons Template
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3INSTRUCTIONS FOR COMPLETING THE HENNEPIN COUNTY
CONCILIATION COURT CLAIM FORM
The following information is required to process your Conciliation Court Claim.
If
required information is not provided, your claim form and filing fee will be returned to
you.
1.
Enter plaintiff(s) name, street address, city, state, zip code and date of birth. (Please
verify that city is correct). One name per box, even for married couples.
NOTE: If more than two plaintiffs use Additional Litigant Form that can be downloaded
from our website at
2.
Enter defendant(s) name, street address, city, state and zip code. Include their telephone
number if known. (Please verify that city is correct) If defendant’s mailing address is a
PO Box, list the street address where they live in the text box for the claim to verify
jurisdiction. One name per box, even for married couples.
NOTE:
If more than three defendants use Additional Litigant Form that can be
downloaded from our website at
3.
Enter the following information:
Amount owed ($15,000 maximum)
Filing Fee - $70.00
Grand Total including filing fee
Date of Incident, event or transaction
Brief description– please use size 10 font or larger and only use the space
provided in the text box. Keep your claim form to one page.
If this is a forfeiture matter, you must include the Notice of Seizure and Intent to
Forfeit
4.
Sign the claim form and include your daytime phone number with area code. Your
signature must be notarized.
Failure to include all of the above will result in your documents being returned to you without
being filed. Do not attach exhibits or other documents to the claim form. Please bring
them to court on the day of your hearing.
Mail or bring your claim form and $70.00 filing fee payable to “Hennepin County Conciliation
Court” to:
Conciliation Court
th
350 South 5
Street
Room 306 – City Hall
Minneapolis MN 55415-0926
CCT102
District4
ENG
Rev 12/12
Page 1 of 3
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