Print Form Clear Form Small Claims Complaint-Verified (Claims under $10,000) (1/03/06) CCM 0750 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS MUNICIPAL DEPARTMENT, __________ DISTRICT _______________________________________________ Plaintiff(s) v. _______________________________________________ Defendant(s) } No. _____________________________________ Amount Claimed: $ _________________________ Return Date: ______________________________ SMALL CLAIMS COMPLAINT-VERIFIED (IL Sup. Ct. Rules 281-288) The Plaintiff(s) claim(s) as follows: 1. Defendant(s) Name(s) and Address(es): ___________________________________________________________ _____________________________________________________________________________________________ 2. Defendant(s) owe(s) me $ ___________________ for the reasons set forth below. 3. Defendant(s) owe(s) me this amount for the following reasons (State nature of your claim including dates and other relevant information. Use additional sheet(s) if necessary): I, __________________________________________, certify that I am the Plaintiff in the above entitled action. (Plaintiff's Name) Under penalties as provided by law pursuant to 735 ILCS 5/1-109 the undersigned certifies that the statements set forth herein are true and correct. Atty. No.: ______________ Atty. (or Pro Se Plaintiff): Name: __________________________________________ Address: ________________________________________ City/State/Zip:___________________________________ Telephone: ______________________________________ Dated:___________________________, ________ Pro Se 99500 ________________________________________ Signature