APPLICATION TO FILE SMALL/COMMERCIAL CLAIM County of: City of: FILING FEE PAYMENT TYPES: By Mail-Money Order or Certified Bank Check In Person- Credit Card or Cash No Personal or Business Checks Accepted! Type of Claim SMALL CLAIM (Individual suing Individual or Company) Filing Fee $15.00 - Claim of $1,000 or less $20.00 - Claim exceeding $1,000 up to $5,000 (Check One) COMMERCIAL CLAIM (Company suing Company) (Required forms - Certificate of Authority & Filing Limitation Certification) $25.00 plus postage for each defendant or additional address (Please contact Clerk's Office for Current Postage Fees) CONSUMER CREDIT TRANSACTION $25.00 plus postage for each defendant or additional address (Please contact Clerk's Office for Current Postage Fees) (Company suing an Individual) (Required forms - Certificate of Authority, Demand Letter & Filing Limitation Certification) COUNTERCLAIM CLAIMANT: (NAME & ADDRESS) Print Name $5.00 plus postage for each claimant (Please contact Clerk's Office for Current Postage Fees) CO-CLAIMANT: (NAME & ADDRESS) Print Name D B.A. D B.A. Street Street City/State/Zip Code Daytime Phone # City/State/Zip Code Daytime Phone # DEFENDANT: (NAME & ADDRESS) Print Name SECOND DEFENDANT: (NAME & ADDRESS) Print Name D B.A. Street D B.A. Street City/State/Zip Code City/State/Zip Code Daytime Phone # Daytime Phone # Amount of Claim: $ Nature of Claim: (Do not include filing fees) Date of Loss: This section MUST be completed and notarized for a CONSUMER CREDIT TRANSACTION or COMMERCIAL CLAIM: I hereby certify, based upon information and belief, that no more than five (5) actions or proceedings (including the instant action or proceeding) have been initiated in the courts of this state during the present calendar month. Claimant's Signature Notary/Clerk's Signature This section MUST be completed and notarized for a CONSUMER CREDIT TRANSACTION: I hereby certify that I have mailed a Demand Letter by ordinary first class mail to the party complained against, no less than ten (10) days and no more than one hundred eighty (180) days before I commenced this action. Claimant's Signature Notary/Clerk's Signature Note: The Commercial Claims Part will not allow your action to proceed if this certification is not properly and completely made. American LegalNet, Inc. www.FormsWorkFlow.com