Plaintiff'S Small Claim Page 2
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3IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR YAMHILL COUNTY
Small Claim
)
)
)
Plaintiff,
Inmate ID No. (if applicable):
)
Case Number:
v.
)
) Small Claim and Notice of Small Claim
)
G
Defendant is a public body
Defendant.
)
Filing Fee located within ORS 46.570
PLAINTIFF(S)
G
Additional plaintiffs on attached page
DEFENDANT(S)
G
Additional defendants on attached page
Plaintiff’s name
Defendant’s name
Street address or Post Office Box number
Street address or Post Office Box number
City / State / Zip
City / State / Zip
Telephone number
County
Telephone number
County
I, plaintiff, claim that on or about
the above named defendant(s)
(date)
owed the sum of $
to me because
, and this amount remains due.
Claim:
$
I paid, or will pay a $
filing fee.
Filing fee:
$
I paid, or will pay a $
service fee.
Service fee:
$
Total due:
$
DECLARATION OF BONA FIDE EFFORT
I, plaintiff, made a bona fide effort to collect this claim from the defendant(s) before filing this claim with the court clerk.
I hereby declare that the above statements are true to the best of my knowledge and belief, and that I understand they
are made for use in court and I am subject to penalty for perjury.
Name of defendant’s registered agent
Street address (do not use a Post Office Box number)
Plaintiff’s signature
City / State / Zip
Telephone number
County
Small Claim and Notice of Small Claim – January 2013
Original to Court and Copy to Defendant(s)
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