Statement Of Claim (Page 2 of 2) in pdf

Statement Of Claim Page 2

1. I hereby claim the defendant owes the plaintiff the sum of $ ______________________

For the following reason: ___________________________________________________

________________________________________________________________________

2. The plaintiff also claims from the defendant court costs in the sum of $______________

Plus $_______________ for interest and $______________ for lawyers’ fees (only if

plaintiff is represented by a licensed, practicing attorney and if the contract or note you

signed so provides.)

NOTE: The total amount of court costs may be more than this amount when the case is

finally settled. The clerk of the court will inform you of any additional costs at the close

of the above listed case.

Clerk’s Address: ________________________________________________________________

_____________________________________________________________________________

Plaintiff or Plaintiff’s Attorney Signature

Attorney Code: _____________________

Plaintiff’s or Plaintiffs Attorney’s Phone Number: _____________________________________

Date of Filing: ____/____/______

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Statement Of Claim Page 2