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Small Claim Complaint Rev. 08-29-18 IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS Plaintiff vs. Defendant ) ) ) ) ) ) ) ) Case No. SMALL CLAIM COMPLAINT I, the Plaintiff herein, claim that the Defendant, , is indebted to the Plaintiff in the sum of $, for . Plaintiff has demanded payment of said sum from the Defendant and he/she refused to pay the same and no part thereof has been paid. Defendant resides at: Plaintiff resides at: Address: Address: City/State/Zip: City/State/Zip: Telephone No: Telephone No: Dated: X Signature of Plaintiff Attorney: Firm Name: ARDC #: Attorney for: Address: City/State/Zip Telephone: E-mail: AFFIDAVIT on oath states that the allegation(s) in this Complaint are true. X Signature of Affiant signed and sworn to before me date (Notary Public) (Clerk) (Judge) (Seal) ORDER Plaintiff in Court Defendant in Court Judgment for $ costs $ stay days. Against Dismissed as to Dated: Judge COURT222S NOTATIONS Vol. Page Date American LegalNet, Inc. www.FormsWorkFlow.com