Superior Court of the District of Columbia CIVIL DIVISION Small Claims Form 11 General SMALL CLAIMS AND CONCILIATION BRANCH Bldg. B, 510 4th Street, N.W., RM –120 WASHINGTON, D.C. 20001 TELEPHONE 879-1120 ____________________________________ (1) ______________________________________ Plaintiff(s) Defendant(s) ____________________________________ vs. (2) ______________________________________ ____________________________________ Address (3) ______________________________________ Zip Code Phone No. ______________________ No. SC ______________ STATEMENT OF CLAIM _____________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ DISTRICT OF COLUMBIA, ss: ______________________________________________________ being first duly sworn on oath says the foregoing is a just and true statement of the amount owing by the defendant to plaintiff, exclusive of all set-offs and just grounds of defense. __________________________________________________________ Plaintiff /Agent (Sign and Print Name) Title:______________________________________________________ ___________________________________________ Address ___________________________________________ City/State/Zip Code Phone No.: __________________________________ Subscribed and sworn to before me this __________ day of ____________________________________________, 20 ________ (month and year) ____________________________________________________ Deputy Clerk (or notary public) ______________________________________________________ Attorney for Plaintiff (Sign and Print Name) ______________________________________________________ Address Zip Code Bar No.: _____________________Phone No.: ________________ NOTICE (All parties must notify the court of any address changes.) To: (1) ___________________________________________ Defendant _____________________________________________ Address Zip Code Home Business (2) _____________________________________________________ Defendant _____________________________________________________ Address Zip Code Home Business You are hereby notified that ___________________________________________________________________________________ ______________________________________________________________________ has made a claim and is requesting judgment against you in the sum of ___________________________________________________________ dollars ($__________________), as shown by the foregoing statement. The court will hold a hearing upon this claim on ____________________________________ __________________________________________________________________________________________________________ at 9:00 a.m. in the Small Claims and Conciliation Courtroom 119, Bldg. B, 510 4th Street, N.W., SEE REVERSE SIDE FOR COMPLETE INSTRUCTIONS BRING THIS NOTICE WITH YOU AT ALL TIMES CV-471/JUL. 06 Deputy Clerk Small Claims and Conciliation Branch American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS TO DEFENDANT(S) IMPORTANT: IF YOU FAIL TO APPEAR AT THE TIME STATED OR AT ANY OTHER TIME THE COURT NOTIFIES YOU TO DO SO, A JUDGMENT BY DEFAULT MAY BE ENTERED AGAINST YOU FOR THE MONEY, DAMAGES OR OTHER RELIEF DEMANDED IN THE STATEMENT OF CLAIM. IF THIS OCCURS, YOUR WAGES OR BANK ACCOUNT MAY BE ATTACHED OR WITHHELD OR ANY PERSONAL PROPERTY OWNED BY YOU MAY BE TAKEN AND SOLD TO PAY THE JUDGMENT. DO NOT FAIL TO APPEAR AT THE REQUIRED TIME. Before any case goes to trial in the Small Claims and Conciliation Branch, a trained mediator will meet with all parties to see if a settlement can be worked out. If all parties are present when your case is called, you and the plaintiff will be able to see a mediator and hopefully settle your dispute without having to go to trial. You may come with or without a lawyer. The Statement of Claim indicates whether the plaintiff has a lawyer. If the plaintiff does have a lawyer and you wish to dispute the claim, it would be in your interest to have your own lawyer. If you wish to have legal advice and feel that you cannot afford to pay a fee to a lawyer, you may contact the Neighborhood Legal Services (682-2700) OR THE D.C. Law Students in Court program (638-4798) or Legal Counsel for the Elderly @ (202) 434-2170 for help or come to Building B, 510 4th Street N.W., Room 120, for more information concerning places where you may ask for such help. You may also consult the D.C. Bar Website at: www.lawhelp.org/dc. Act Promptly. If it is impossible for you to appear on the date of trial, attempt to contact the Plaintiff to arrange a new date. If parties agree on a date, notify the clerk of the Small Claims Branch of this court in person or by phone of the new date. If parties cannot agree, you may contact the clerk who will inform you regarding procedures. If you do not appear on the new date, a judgment may be entered against you. Whenever corresponding with the Small Claims clerk's office by mail, please include your case number and your date to appear in court. You are given the following additional instructions in the event that you intend to appear without a lawyer. If you have witnesses, books, receipts, or other writings bearing on this claim, you should bring them with you at the time of the hearing. If you wish to have witnesses summoned, see the clerk at once for assistance. If you admit the claim but desire additional time to pay, you must come to the hearing in person and state the circumstances to the Court. PUEDE OBTENERSE COPIAS DE ESTE FORMULARTO EN ESPANOL EN EL TRIBUNAL SUPERIOR DEL DISTRITO DE COLUMBIA, BUILDING B, 510 4TH STREET N.W., SALA 120. YOU MAY OBTAIN A COPY OF THIS FORM IN SPANISH AT THE SUPERIOR COURT OF D.C., BUILDING B, 510 4TH STREET N.W., ROOM 120. CV-471/JUL. 06 American LegalNet, Inc. www.FormsWorkflow.com