APPLICATION TO FILE SMALL CLAIMS Ninth Judicial District For Court Use only Page 1 of 1 City Court of: ______________________________________ County of: ______________________________________ 9 9 PAYMENT OPTIONS: Index No. _________________________________________ Filed Date _________________________________________ Court Date________________________________________ CASH, MONEY ORDER, CERTIFIED BANK CHECK CREDIT CARD - VISA, MASTERCARD OR DISCOVER ONLY NO PERSONAL OR BUSINESS CHECKS ACCEPTED SC- $15.00 - Claim of $1,000 or less $20.00 - Claim over $1000 up to $5,000 $ 5.00 - Counterclaim + .47 Postage Per Defendant PLAINTIFF: (NAME & ADDRESS - No P.O. Boxes) Print Name ___________________________________ D.B. A. Street _____________________________________ ______________________________________ CO-PLAINTIFF: (NAME & ADDRESS - No P.O. Boxes) Print Name _______________________________________ D. B.A. Street ________________________________________ _________________________________________ City/State/Zip Code _____________________________ Daytime Phone # _______________________________ City/State/Zip Code ________________________________ Daytime Phone # __________________________________ 2nd DEFENDANT: (NAME & ADDRESS - No P.O. Boxes) DEFENDANT: (NAME & ADDRESS- No P.O. Boxes) Defendant must reside in the same County as the City Court where this application is filed Print Name ___________________________________ D.B.A. Street ____________________________________ _____________________________________ Print Name _______________________________________ D.B.A. __________________________________________ Street _________________________________________ City/State/Zip Code ________________________________ Daytime Phone # __________________________________ City/State/Zip Code ____________________________ Daytime Phone # ______________________________ Amount of Claim (Do not include filing fees) : $ ________________ What date did this occur?________________________ Briefly state reason for claim: Choose only ONE of the following reasons for this claim: 9 Breach of contract or warranty 9 Breach of lease or rental agreement 9 Breach of warrant of habitability 9 Car rental expense 9 Confirm arbitrator's award 9 Damages caused to automobile 9 Dishonored check 9 Failure to pay for medical services 9 Failure to issue a refund 9 Failure to pay for commissions 9 Failure to pay for insurance claim 9 Failure to pay for services rendered 9 Failure to pay for wages 9 Failure to pay for goods ordered 9 Failure to provide proper services 9 Failure to return property 9 Goods sold and delivered 9 Late Fees 9 Loss of personal property 9 Loss of profit 9 Loss of time for work 9 Loss of use property 9 Medical malpractice 9 Monies due 9 Motor vehicle negligence 9 Other 9 Payment of loan 9 Personal Injuries 9 Professional fees 9 Property damage 9 Refund on defective merchandise 9 Refund on defective work, labor, services 9 Return of deposit 9 Return of security 9 Termination 9 Unpaid wages 9 Veterinary bill 9 Work, labor or services ______________________________________________________ Signature of person filing claim American LegalNet, Inc. www.FormsWorkFlow.com __________________ Today's Date 9JD-SC-APP (4/2016)