SUPERIOR COURT OF THE DISTRICT OF COLUMBIA Civil Division Small Claims and Conciliation Branch 510 4th Street, N.W., Court Building B, Room 120, Washington, D.C. 20001 Telephone Number: (202) 879-1120 Website: www.dccourts.gov Plaintiff(s) v. ( The information collected on this form is used solely for court administration and statistical purposes. ) Defendant(s) Name ( please print or type ) Relationship to Lawsuit : Attorney for Plaintiff Self (Pro Se / No Attorney) Other: Firm Name ( if applicable ) T elephone No. Bar. No . Service Method : Certified Mail by Clerk (How many? ) With Restricted Delivery ( check if applicable ) Registered Mail by Clerk (How many? ) With Restricted Delivery ( check if applicable ) Special Process Server (You must file an Application for Approval of Special Process Server) Do you nee d an interpreter? Yes No If yes, which language(s)? A mount in Controversy : $1 - $500 $50 0.01 - $2,500 $2,50 0.0 1 - $ 10 ,000 P ending or re - filed case(s) related to the action being filed: Case No . : Case No . : NATURE OF SUIT: ( Check ONE box only that most accurately describes your primary case) A. CONTRACTS a claim based on an agreement between parties made either orally or in writing Breach of Contract Negotiable Instrument Unpaid Wages Debt Suit Brea ch of Warranty Loan Services Rendered Home Improvement Contract Personal Property Rent Due Security Deposit Oral B. PROPERTY TORTS a claim for a n injury or wrong committed on the property of another Automobile Property Damage Conversion Destruction of Property Shop Lifting Trespass C. PERSONAL TORT S a claim for a n injury or wrong com mitted on the person of another Assault and Battery Automobile Personal Injury Fraudulent Misrepresentation Libel and Slander Slip and Fall Negligence D. UNIFORM ARBITRATION ACT an action based on an arbitration agreement E . SUBROGATION a claim filed by one person in the place of another F . FOREIGN JUDGMENT (DOMESTIC) judgment, decree or order filed from another jurisd iction G . COLLECTION a claim filed by a seller / lender to collect a consumer debt H . FOREIGN JUDGMENT (INTERNATIONAL) judgment, decree or order filed from another country I . MEDICAL MALPRACTICE a claim against a healthcare provider for professional misconduct Have you given notice of intention to file your lawsuit 90 days prior to filing? Yes No CV-3046/Rev. Sept. 2018 American LegalNet, Inc. www.FormsWorkFlow.com