IN THE CIRCUIT COURT FOURTH JUDICIAL CIRCUIT CLINTON COUNTY, ILLINOIS Case Number'~_ _ _ _ _ _ __ Plaintiff(s) Defendant(s) SMALL CLAIM COMPLAINT I, the undersigned, claim that the defendant is indebted to the plaintiff in the sum fur _______________________ of $ _ _ _ _ _ _ __ and that the plaintiff has demanded payment of said sum; that the defendant refused to pay the same and no part thereof has been paid; that the defendant resides at _ _ _ __ Phone No. _ _ _ _ _ _ _ _ _ _ _ _; that the plaintiff resides at _______ _ _ _ _ _ _~Phone Number. _ _ _ _ _~_____ in the State of lIIinois. Date (Month / Day / Year) (Signature of Plaintiff) Signed and sworn before me _____________, J _~ ~ _ __ Notary Public Clerk of the Court American LegalNet, Inc. www.FormsWorkFlow.com