Statement of Small Claim and Notice of Trial Docket No. Trial Court of Massachusetts Small Claims Session G District Court ________________Division G Housing Court ________________Division Part 1: G Boston Municipal Court Part 2: Plaintiff’s Name, Address, Zip Code and Phone Plaintiff’s Attorney (If any) ___________________________________________ Name:_________________________________________________ _______________________________ ________ Address: ______________________________________________ ___________________________________________ _______________________________________________________ Phone No: _________________________________ Phone No: _____________________________________________ ______________________________________________________________________________________________________ Part 3: Defendant’s Name, Address, Zip Code and Phone Additional Defendant (If any) _____________________________________________ _______________________________________________________ _____________________________________________ _______________________________________________________ _____________________________________________ _______________________________________________________ Phone No: ___________________________________ Phone No: _____________________________________________ ______________________________________________________________________________________________________ Part 4: PLAINTIFF’S CLAIM: The defendant owes $____________________ plus $_______________ court costs for the following reasons: Give the date of the event that is the basis of your claim. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Signature of plaintiff x _____________________________________________________Date: ________________________ ______________________________________________________________________________________________________ Part 5: MEDIATION: Mediation of this claim may be available prior to trial if both parties agree to discuss the matter with a mediator, who will assist the parties in trying to resolve the dispute on mutually agreed to terms. The plaintiff must notify the court if he or she desires mediation; the defendant may consent to mediation on the trial date. G The plaintiff is willing to attempt to settle this claim through court mediation. ______________________________________________________________________________________________________ Part 6: MILITARY AFFIDAVIT: The plaintiff states under the pains and penalties of perjury that the: G above defendant(s) is (are) not serving in the G above defendant(s) is (are) serving in military and at present live(s) or work(s) at the the military. above address. X ___________________________________ _______________ Signature of plaintiff Date ______________________________________________________________________________________________________ Notice of Trial: Name and Address of Court NOTICE TO DEFENDANT: You are being sued in Small Date and Time of Trial: Claims Court by the above named plaintiff. You are directed to appear for trial of this claim on the date and time noted to the right. American LegalNet, Inc. www.USCourtForms.com