CCT202 State ENG Rev 8/15www.mncourts.gov/formsPage 1 of 2State of MinnesotaConciliation Court County of: Select County Court File Number: Judicial District: Case Type: Conciliation Name: Address: City/State/Zip STATEMENT OF COUNTERCLAIM AND SUMMONSPlaintiff #1 Name: Address: City/State/Zip: Defendant #1 Name: Address: City/State/Zip: Name: Address: City/State/Zip Plaintiff #2Defendant #2P L E A S E P R I N T vsvsDEFENDANT222S STATEMENT OF COUNTERCLAIM 1.The Plaintiff(s) owe(s) me plus filing fees and costs of for a total of, because on or about (state the month and year) the following event occured (briefly describe the event) : 2.The Plaintiff(s) has/have the following property that belongs to me (list property), valued at , plus filing fees and costs of for a total of. I want the court to order this property returned tome or make the Plaintiff(s) pay me money for the value of the property.3.I believe the person(s) I am suing is/are at least 18 years old and not in the military service. Plaintiff #1 date of birth . Plaintiff #2 date of birth.4.I understand that if I do not come to court on my hearing date, my case will be dismissedand I may have to pay money to the Plaintiff(s) on any claim that has been filed. Signature I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116.Dated: American LegalNet, Inc. www.FormsWorkFlow.com CCT202 State ENG Rev 8/15www.mncourts.gov/formsPage 2 of 2 Defendant #1 date of birth: Telephone: City/State/Zip: Address: Title, if any: Printed Name: Defendant #2 date of birth: E-mail address: County and State where signed 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, call Conciliation Court. 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 filed.NOTICE OF SETTLEMENT The above-entitled case having been settled, the same may be and hereby is dismissed with my consent. Date: Defendant's Signature American LegalNet, Inc. www.FormsWorkFlow.com