STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT ROCK ISLAND COUNTY Complaint_______________________________ No._____________________________ ________________________________________ ________________________________________ VS ________________________________________ (PLAINTIFF(S)) ________________________________ ________________________________ ________________________________ (DEFENDANT(S)) SMALL CLAIM COMPLAINT I, the undersigned, claim that the defendant is indebted to the plaintiff in the sum of ___________________ $_________________________________for__________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ and that the plaintiff has demanded payment of said sum; that the defendant refused to pay the same and no part thereof has been paid; that the defendant resides at _________________________________________ ______________________________________________________________________________________ ___________________________________________phone no._________________:in the state of Illinois. Dated___________________________,20______ ____________________________________ (Signature of Plaintiff) AFFIDAVIT _____________________________________on oath states that the allegations in this complaint are true. Signed and Sworn to Before me _____________________________,20_______ _______________________________________ (Notary Public) ___________________________________________ (Seal) SMALL CLAIM DOCKET Complaint filed on _________________________by_______________________________________Clerk Date reset________________________________ by_______________________________________Clerk Date reset________________________________ by_______________________________________Clerk Fees Clerk’s________________________________________Plaintiff in Court____________________________________ Certified mail___________________________________Deft in Court ____________________________________ Sheriff_________________________________________Judgment for ______________________________________ Execution______________________________________$__________________costs $_________________________ ______________________________________________stay________________days___________________________ _____________________________________________ Against____________________________________________ _____________________________________________ ____________________________________________ _____________________________________________Dismissed as to______________________________________ _____________________________________________ ____________________________________________ COURT’S NOTATIONS Vol.__________________________________Page_________________Date_______________________20________ American LegalNet, Inc. www.USCourtForms.com