COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : PLAINTIFF’S STATEMENT TO CLERK Index No. NAPA SUPERIOR COURT SMALL CLAIMS DIVISION : Calendar No. PLEASE READ THE FORM (SC-150) ENTITLED ‘INFORMATION FOR PLAINTIFF’ : JUDICIAL SUBPOENA Plaintiff(s) BEFORE FILLING OUT THIS FORM -against- 1. Was demand made on Defendant for payment of the amount sued for? WHEN? WHERE? 2. Yes No : Orally : Give your name and residence address and the name and address of any other person joining with you in this action. transaction, give the following information: Individually owned business Partnership In Writing If this claim arises from a business : Corporation If partnership, give the full name of all partners: Defendant(s) : ...................................................... Address: 3. Telephone: If you PEOPLE OF THE the full name and address of each THE are suing individuals, give STATE OF NEW YORK person you are suing. If you are suing a business, give the firm name, name of owner and the business. If you are suing a partnership, give the firm name, name of the partners and the business address. If you are suing a corporation, give its full TOname and address. If your suit arises out of an automobile accident, you must name the driver and should also name the registered owner as a defendant in this action and give their addresses. If your suit is against a minor, give his age, name and addresses of parents having custody. Name: Address: GREETINGS: Name: Address: 4. 5. 6. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Amount of Claim: $ , the Honorable at the Court Fully state the nature of your claim: located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the If your claim arises from an automobile accident, please answer the following: Street address or locality of accident: Lowest of two estimates to repair damage: Was citation issued to either driver? Your failure to comply with this subpoena expenses: is punishable as a contempt of court and will make you liable to Medical the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Other items of damage: result of your failure to comply. Wages lost due to injury: Registered owner of car you were in: 7. If claims arises from rental agreement, please complete the following: Witness, Honorable Address of rental premises: Courtrate? $ in County, Rental per , one of the Justices of the day of estimate to repair20 , damages to premises if claimed: . Lowest Rent is for the period of time from to Name of person you rented to or from Amount of security deposit, if any: Date premises vacated: Was it returned? Date premises re-rented: Was notice given in writing before tenant moved? 8. (Attorney must sign ALL and type name below) above PART YES NO WHEN? If claim is for money due for goods or services rendered, complete the following: Attorney(s) for Date and place of agreement to pay? What goods were purchased or what services rendered? Office If open book account, date of last charge, other than service fee or date of last payment? and P.O. Address Place where payment was to be made or service was rendered? 9. I have received and read the form entitled “INFORMATION TO PLAINTIFF” I DECLARE UNDER PENALTY OF PERJURY THE FOREGOING IS TRUE AND CORRECT. DATE: Telephone No.: Facsimile No.: E-Mail Address: Signature of Plaintiff or Declaring Party Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com