CCT102 State ENG Rev 2/17www.mncourts.gov/formsPage 1 of 3State of MinnesotaConciliation Court County of: Select County Court File Number: Judicial District:Case Type:ConciliationSTATEMENT OF CLAIM AND SUMMONS Plaintiff #1 Name: Address: City/State/Zip Defendant #1 Name: Address: City/State/Zip: Plaintiff #2 Name: Address: City/State/Zip: Defendant #2 Name: Address: City/State/Zip Check box if there are more than two plaintiffs or more than two defendants. List theinformation for the other parties on the Additional Litigants Form, CCT702.PLAINTIFF'S STATEMENT OF CLAIM1.I am filing this claim against Defendant for: (check all that apply) The Defendant owes me $ , plus filing fees and costs in the amount of $ , so my total claim is for$ (amount Defendant owesplus filing fees and costs). I have a claim for this amount because in (month and year), the following happened (briefly describe): The Defendant has the following property that belongs to me (list property): My property is valued at $. The filing fees and costs for this case are $ . I want the court to order this property returned to me or make the Defendant pay me $(property's value plus the filing fees and costs).2.I believe the person I am suing is at least 18 years old. Defendant #1 date of birth:/ Unknown. Defendant #2 date of birth:/ Unknown.If a defendant is a business, leave this section blank for that defendant. American LegalNet, Inc. www.FormsWorkFlow.com CCT102 State ENG Rev 2/17www.mncourts.gov/formsPage 2 of 33.About military service:Defendant #1 is in the military service / is not in the military service Unknown.Defendant #2 is in the military service / is not in the military service Unknown.If a defendant is a business, leave this section blank for that defendant.4.I understand that if I do not come to court on my hearing date, my case may be dismissedand I may have to pay money to the Defendant on any counterclaim that has been filed.I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116.Important! Each plaintiff must sign the Statement of Claim and Summons form and include the date signed, the name of the state and county where signed, and provide the following information: title, if any, telephone number, and e-mail address. Dated: Signature /s/ County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com CCT102 State ENG Rev 2/17www.mncourts.gov/formsPage 3 of 3SUMMONS: IMPORTANT NOTICE TO THE PARTIES You are summoned to appear at the hearing of the above-entitled case. See the attached Notice of Hearing for time and location. If not attached, call Conciliation Court inCounty.If the defendant does not appear at the hearing, the plaintiff may win this case by default, which means the plaintiff could be awarded a money judgment against the defendant. The judgment could include the amount the plaintiff requested in the Statement of Claim as well as other fees and costs approved by a judicial officer. If the plaintiff does not appear at the hearing, this case may be dismissed. If the defendant has filed a counterclaim, then a default judgment could be entered against the plaintiff. The Defendant may bring a counterclaim against the Plaintiff. A counterclaim must be filed at least five days before the Conciliation Court hearing. For forms, instructions, and more information, see Information About Conciliation Court (court form CCT101) on the court222s website starting at www.mncourts.gov/forms. NOTICE OF SETTLEMENT The above-entitled case has been settled, and is dismissed with my consent. Important! Each plaintiff who has settled the case must sign and date this 223Notice of Settlement224 section. Dated: Signature American LegalNet, Inc. www.FormsWorkFlow.com