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 indebt ised to the plaintiff in the sum of ___________________ $_________________________________for__________________________________________________ ________________________________________________________________________ ______________ ______________________________________________________________________________________ and that the plaintiff has demanded payment of said sum; that the defendant refused to pay the same and no part thereof has been paid;at th the defendant resides at _________________________________________ ______________________________________________________________________________________ ___________________________________________phone no._________________:in the state of Illinois. Dated___________________________,20______ ____________________________________ (Signature of Plaintiff) AFFIDAVIT _____________________________________on oath states that the allegations in this complaint are true. Signed and Sworn to Before me _____________________________,20_______ ____________ _______________________________ _______________________________________ (Seal) (Notary Public) SMALL CLAIM DOCKET Complaint filed on _________________________by_______________________________________Clerk Date reset________________________________ by_______________________________________Clerk Date reset________________________________ by_______________________________________Clerk Fees Clerks________________________________________Plaintiff in Court____ ________________________________ Certified mail___________________________________Deft in Court _____ _______________________________ Sheriff_________________________________________Judgment for ___________ ___________________________ Execution______________________________________$__________________costs $_________________________ ______________________________________________stay________________days___________________________ _____________________________________________ Against___________________ _________________________ _____________________________________________ ______________ ______________________________ _____________________________________________Dismissed as to____________ __________________________ _____________________________________________ ______________ ______________________________ COURTS NOTATIONS Vol.__________________________________Page_________________Date_________ ______________20________ American LegalNet, Inc. www.USCourtForms.com