COMMONWEALTH OF MASSACHUSETTS ________________,SS: HOUSING COURT DEPARTMENT _______________ DIVISION / / / - / / / / / / SMALL CLAIMS NO. CLAIM OF APPEAL FROM A SMALL CLAIMS JUDGMENT Plaintiffs Name, Address and Zip Code _____________________________________ _____________________________________ _____________________________________ _________________________________ Telephone Defendants Name, Address and Zip Code ______________________________________ ______________________________________ ______________________________________ _________________________________ Telephone I hereby claim a trial of this small claims before a Housing Court jury, pursuant to Ge neral Laws chapter 218, 23 and Chapter 185C, 3. I received the courts Notice of Judgment in this case on __________________ _____, 20____. I state on oath that this claim of jury trial is intended in good faith, and there are questions of fact and law requiring a jury trial, specifically : ________________________________________________________________________ _____ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ This is signed under the penalties of perjury: _________________________ _____________ ________________________________________________________________________ _____________ Date: Defendants Signature: American LegalNet, Inc. www.USCourtForms.com