IN THE CIRCUIT COURT OF THE TWENTY-SECOND JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS _________________________________________________ _________________________________________________ _________________________________________________ Plaintiff(s) vs. _________________________________________________ _________________________________________________ _________________________________________________ Defendant(s) Case Number_________________________________ SMALL CLAIM COMPLAINT I, the undersigned, claim that the defendant(s) is/are indebted to the plaintiff(s) in the sum of $_____________________________ for ______________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ and that the plaintiff(s) has/have demanded payment of said sum; and that the defendant(s) refused to pay the same and no part thereof has been paid; that the defendant(s) resides/reside at_________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Phone number__________________________________________________; that the plaintiff(s) resides/reside at______________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Phone number__________________________________________________; in the State of Illinois. Date _______________________________________ (Month Day Year) _____________________________________________________________ _____________________________________________________________ Signature of Plaintiff(s) VERIFICATION That ____________________________________, under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedures, the undersigned certifies that the statements set forth in this instrument are true and correct. ____________________________________________________________ _____________________________________________________________ Signature of Plaintiff(s) McHenry County Clerk of the Circuit Court 2200 N. Seminary Avenue, Woodstock IL 60098 SC-CMP1: Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com