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In The District Court of

County, Kansas

Case Number _____________

________________________________________________________________________________________________________

Plaintiff – name and address

________________________________________________________________________________________________________

Defendant – name and address

Pursuant to Chap. 61 of K.S.A

DEFENDANT’S CLAIM

INSTRUCTIONS:

As stated in the summons, if you have a claim against the plaintiff which arises out of the transaction or occurrence which is the subject of

plaintiff’s claim, and you claim does not exceed $4000.00, you may state your claim in the space provided below. In determining whether or

not your claim against the plaintiff exceeds $4000.00, do not include interest, costs and any damages under K.S.A. 1989 Supp. 60-2610, but do

include the value of any personal property sought to be recovered as determined by your estimate of its value under oath.

Be clear and concise in stating your claim.

If the value of your claim exceeds $4000.00 (not including interest, costs, and any damages awarded under K.S.A. 60-2610, but including the

value of any personal property to be recovered, as determined by our estimate of its value under oath), the court must decide whether or not you

may pursue the entire claim or only that portion not exceeding $4000.00.

If your claim exceeds $4000.00 and the court determines that you may not pursue the entire claim, at the hearing you have three alternatives:

(1) Make no demand for judgment and reserve the right to pursue your entire claim in a court of competent jurisdiction. (2) Make demand for

judgment of that portion of your claim which does not exceed $4000.00 and reserve the right to bring an action in a court of competent

jurisdiction for any amount in excess thereof. (3) Make demand for judgment of that portion of your claim which does not exceed $4000.00

and waive your right to recover any excess.

When completed, this form must be filed with the clerk of the district court before the time stated in the summons for the trial.

STATEMENT OF CLAIM:

I, ________________________________, having read the instructions above, assert the following claim against,

__________________________________________, plaintiff.

_______________________________________________________________________________________________________________________

DEMAND FOR JUDGMENT:

Based on the claim stated above, judgment is demanded against plaintiff as follows:

1). Payment of $_________________, plus interest, costs and any damages awarded under K.S.A. 60-2610.

Recovery of the following described personal property, plus costs:

I, ____________________________________, hereby swear that, to the best of my knowledge and belief, the above claim asserted against the plaintiff,

(including the estimate of value of any property sought to be recovered) is a just and true statement.

_____________________________________

(Signature of Defendant)

Subscribed and sworn to before me this ______ day of __________________________, 20____.

_____________________________________

Judge/Clerk/Notary

Petition - Kansas District Court, Summons - Kansas District Court, Defendant'S Claim - Kansas District Court Etc. Page 7