Clerk’s Use Only IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS Small Claims Division _______________________________________________________________ Plaintiff Phone No. _______________________________________________________________ Address, City, State, Zip Code Vs. ______________________________________________________________________________________ Defendant Phone No. ______________________________________________________________________________________ Address, City, State, Zip Code Case No. _____ SC ___________ INSTRUCTIONS TO PLAINTIFF: 1. 2. 3. 4. 5. 6. 7. 8. State the claim you have against defendant in the space provided. Be clear and concise. You must file the original and 2 copies of this petition. Your total claim against defendant may not exceed $4,000.00 not including interest, costs and any damages awarded under KSA 1989 Supp. 602610. If you are seeking the recovery of personal property, the value of that property shall be based on your estimate of its value under oath. You must be present in person at the hearing in order to avoid default judgment against you on any claim defendant may have which arises out the transaction or occurrence which is the subject of your claim. You must make demand for judgment in one or both of the spaces provided. Neither you nor the defendant is permitted to appear with an attorney at the hearing. You may not file more than 10 petitions under the small claims procedure act during any calendar year. You should keep the court informed of any changes in your address or phone number. After completing this form, you must subscribe to the oath below. PETITION PURSUANT TO CHAPTER 61 OF THE KANSAS STATUTE ANNOTATED STATEMENT OF CLAIM: I, _______________________________________________________________, having read the above instructions, hereby assert the following claims against the Defendant(s): DEMAND FOR JUDGMENT: Based on the claim stated above, judgment is demanded against defendant as follows: 1. Payment of $_____________________, plus interest and any damages awarded under KSA 1989 supp. 60-2610. 2. Recovery of the following described personal property, plus costs:________________________________________. This personal property has an estimated value of $______________________. OATH: I, _________________________________________________________________, hereby swear that, to the best of my knowledge and belief, the foregoing claim asserted against defendant (including the estimated value of any property sought to be recovered) is a just and true statement, exclusive of any valid claim or defense which defendant may have. ____________________________________________________ Plaintiff (Signature) Subscribed and sworn before me this ____________ day of __________________________, 20______. My commission expires:___________________ ___________________________________________________________ Deputy Clerk of District Court/ Notary Public American LegalNet, Inc. www.USCourtForms.com