AOC- 175 Rev. 5-11 Page 1 of 2 Doc. Code: COM COM M O NW E A LT H O F K E lex et justitia Case No. ____________________ Court _______________________ District Small Claims County ______________________ NT U C KY CO Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 24A.260 U RT OF JUS TI SMALL CLAIMS COMPLAINT C E Assigned Court Date: ___________________________ Plaintiff: Name Address [ ] Company [ ] Individual (for individual, enter first, middle and last names) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Plaintiff's Attorney (if any): Name Address [ ] Firm [ ] Individual __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Defendant: Name Address [ ] Company [ ] Individual (for individual, enter first, middle and last names) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ NOTICE TO EACH DEFENDANT - READ CAREFULLY You are being sued in Small Claims Court by the Plaintiff shown above. The judge has not made a decision in this case. You are to appear in court on the date shown on the attached summons to tell your side of the dispute. If you fail to appear in court on the date shown on the attached summons, a court judgment may be taken against you for the money or property demanded in the Claim on page 2 of this document. This could lead to garnishment of your paycheck and/or sale of your home or other belongings (unless protected by law) to satisfy the judgment. If you have questions or need assistance, consult the Small Claims information pamphlet (P-6) or call an attorney. WARNING REGARDING JURY TRIAL (KRS 24A.320; 29A.270) There are no jury trials in Small Claims Court. If the amount in controversy exceeds $250, you may have a jury trial by going into District Civil Court. However, the simplified and informal procedures used in Small Claims Court do not apply in District Civil Court. If you request a jury, you will be required to pay an additional fee. To the Plaintiff: To The Defendant: If you want a jury trial, file your claim in District Civil Court instead of Small Claims Court If you want a jury trial, you must notify the court clerk in writing at least seven (7) days before the court date listed on the attached summons to have the case transferred from Small Claims Court to District Civil Court. Clerk Address ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Phone No. ___________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com AOC 175 Rev. 5-11 Page 2 of 2 Doc. Code: COM Plaintiff's Name ____________________________________________ CLAIM 1. Plaintiff claims Defendant: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ NOTE TO PLAINTIFF: Only the Complaint will be served on the Defendant. Attachments WILL NOT be served. 2. Plaintiff claims the sum of $ _______________________ from the defendant for damages incurred as a result of the above complaint. (The jurisdictional authority of Small Claims Court is $2,500.00, exclusive of interest and costs. KRS 24A.230). 3. Plaintiff also claims the following court costs: _____________________________________________________. Court costs will be added to any judgment rendered in favor of plaintiff. Date: ___________________________, 2______. _______________________________________________ Plaintiff's or Attorney's Signature SMALL CLAIMS AFFIDAVIT KRS 24A.250(1) reads as follows: No party shall file more than twenty-five (25) claims in any one (1) calendar year in the Small Claims Division of any District Court in the Commonwealth. Any business engaged in trade or commerce shall be entitled to the maximum number of claims allowed under this section of each established location in the district that has been engaged in trade or commerce for at least six (6) months. KRS 24A.250(4) exempts claims brought by city, county or urban-county governments from the limit on the number of claims that may be filed in a calendar year. I swear (or affirm) I have not brought more than the maximum number of claims allowed by KRS 24A.250. Date: ____________________________, 2_______. ___________________________________________ Affiant's Signature Subscribed and sworn to before me by ________________________________________________ this ____________ day of _________________________