Plaintiff #1 Address City/State/Zip Date of Birth: Plaintiff #2 Address City/State/Zip Date of Birth: VERSUS Defendant #1 Address City/State/Zip Date of Birth: Defendant #2 STATEMENT OF COUNTERCLAIM STATE OF MINNESOTA COUNTY OF HENNEPIN FOURTH JUDICIAL DISTRICT CONCILIATION COURT Case Number: 27-CO-_____________________ The plaintiff(s) owe defendant(s) $_______________________, plus a $ ______ filing fee, for a total of $____________________, plus costs, because on or about (month / year) ______________________, _____, the following event occurred. Briefly describe the event below. Address City/State/Zip Date of Birth: Defendant #3 Address City/State/Zip Date of Birth: Office use only � SPECIAL SERVICE Certified Secretary of State Personal Service Other I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. � 358.116. The person(s) being sued are at least 18 years old and are not in the military service. Signed: Date signed: County where signed: State where signed: Title of representative (if applicable): Daytime telephone: (_____) SUMMONS: IMPORTANT NOTICE TO THE PARTIES You are hereby summoned to appear at the hearing of the above-entitled case. See the attached Notice of Hearing for time and location. If not attached, please call Conciliation Court at (612)348-2713. Failure of defendant to appear at the hearing may result in a default judgment being entered for the plaintiff. Failure of the plaintiff to appear may result in dismissal of the action or a default judgment being entered in favor of the defendant on any counterclaim that has been asserted. See Information About Conciliation Court (#CCT101) available on the court's website at www.mncourts.gov/forms. Notice of Settlement The above-entitled case having been settled, the same may be and hereby is dismissed with my consent. Date: Plaintiff's signature CCT202 Dist4 ENG Rev 04/16 www.mncourts.gov/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com