IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI SMALL CLAIMS COURT AT KANSAS CITY AT INDEPENDENCE ______________________________________ PLAINTIFF(S) ______________________________________ No. ____________________________ ______________________________________ _______________________________ STREET ADDRESS DATE, TIME AND DIVISION OF HEARING ______________________________________ _______________________________ CITY STATE ZIP RECEIPT NUMBER _________________________________________________________ Personal Service Requested RES. PHONE WORK PHONE Private Process Server Certified Mail Service Requested Delivery Restricted to Addressee VS. _________________________________________________________ _______________________________________________ DEFENDANT(S) _________________________________________________________ _______________________________________________ _________________________________________________________ _______________________________________________ SERVICE ADDRESS _________________________________________________________ _______________________________________________ CITY STATE ZIP PETITION Plaintiff states that he has a claim against the defendant, which arose on or about___________________________, in the amount (DATE) of $______________________. Defendant is a resident of __________________ County, in the State of ___________________. The claim arose in _______________________________ County, the State of _______________, due to the following events:___ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Plaintiff states that the information contained in this petition is true and correct to the best of his knowledge, that he is not an assignee of this claim and that he has not filed more than eight other claims in any Missouri small claims court during the current calendar yea r. Plaintiff understands that should he be successful in this action and obtain a judgment, and if defendant does not appeal withi n 10 days, this judgment becomes final. Plaintiff cannot commence another action involving the same parties and issues. Plaintiff also understands that any amount over the small claims monetary jurisdiction owed by defendant arising out of this transaction is deemed waived . PLAINTIFF IS HEREBY WAIVING HIS RIGHT TO JURY TRIAL ON THESE ISSUES IN THE SMALL CLAIMS COURT. KEEP A COPY OF THIS PETITION AND BRING IT TO COURT __________________________________________ SIGNATURE OF PLAINTIFF CIRCT 4202 - 12/97 ORIGINAL (FILE IN COURT=S CASE FILE FOLDER)