Commercial Claims Complaint Form
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1NASSAU DISTRICT COURT - COMMERCIAL CLAIMS COMPLAINT FORM
STATE DETAILS OF YOUR CLAIM: _____________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Date of Occurrence or Transaction: ______/_______/_______
Total Amount of Claim ($5,000 Maximum) ______________
CLAIM ANT’S Information (No P.O. Boxes)
Check One -
Consumer Transaction
Commercial Transaction
Legal Business Name______________________________________________________________________________
DBA_____________________________________________________________________________________________
Address:_________________________________________
City________________________ State _________ Zip______________
DEFENDANT’S Information (M ust Have Nassau County Address - No P.O. Boxes)
First Name ______________________ M iddle ________________ Last ______________________________________
or Legal Business Name ____________________________________________________________________________
Address:_________________________________________
City________________________________ State NY Zip______________
CERTIFICATION (Section 1803-A & 1809-A UDCA)
I____________________________________________(nam e) am a/an _______________________________________
(officer, director or em ployee) of______________________________________________________________________
(claim ant-corporation, partnership or association) and have been authorized to represent the claim ant in this com m ercial
claim action, which has its principal office in the State of New York. I certify to the truthfulness of the within claim and that
no m ore than five (5) such actions or proceedings (including the instant action or proceeding) have been initiated during
the present calendar m onth. I further certify that I have the requisite authority to bind the corporation, partnership or
association in a settlem ent or trial of any action or counterclaim .
The undersigned acknowledges that they shall be deem ed to have waived all rights to appeal except on the sole ground
that substantial justice has not been done. The undersigned has also been advised that supporting witnesses, account
books, receipts and other docum ents required to establish the claim m ust be produced at the hearing.
If this clam is arising out of a consum er transaction, I hereby certify that I have m ailed a dem and letter by ordinary first
class m ail to the party com plained against no less than ten (10) and no m ore than one hundred eighty (180) days before I
com m enced this claim .
_______________________________
___________
________________________________
Signature of Claimant
Date
Clerk or Notary
COURT USE ONLY BELOW THIS LINE
Index Number __________________________
Hearing Date________________
Breach of Contract or W arranty
Failure to pay for wages
Personal Injuries
Breach of Lease or Rental
Failure to provide goods ordered
Professional Fees
Agreem ent
Failure to provide proper services
Property Dam age
Car Rental Expenses
Failure to return property
Refund on Defective Merchandise
Consum er Credit
Goods Sold and Delivered
Refund on Defendant's Defective
W ork, Labor and/or Services
Dam ages caused to autom obile
Late Fees
Rent Due
Dishonored Check
Loss of Personal Property
Return of Deposit
Failure to Pay for Medical Services
Loss of Profit
Provided
Return of Security
Loss of tim e for work
Failure to issue a refund
Unpaid W ages
Loss of use of property
Failure to pay for com m issions
W ork, Labor and Services
Monies Due
Failure to pay for insurance claim
Paym ent of Loan
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