COMMERCIAL CLAIMS APPLICATION Ninth Judicial District For Court Use only Page 1 of 2 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 O NLY NO PERSONAL OR BUSINESS CHECKS ACCEPTED CC- $25.00 + 5.58 Postage Per Defendant $ 5.00 - Counterclaim + .47 Postage Per Defendant $5.58 postage includes: .465 First Class mail, .465 First Class Mail, 3.30 Certified Mail and 1.35 Electronic Return Receipt $5.59 -Please type or print all information clearly- CLAIMANT: (NAME & ADDRESS - No P.O. Boxes) Business Name ________________________________ D.B. A. _____________________________________ Principal Office address _________________________ City/State/Zip Code _____________________________ Daytime Phone # _______________________________ DEFENDANT: (NAME & ADDRESS- No P.O. Boxes) CO-CLAIMANT: NAME & ADDRESS - No P.O. Boxes) Business Name ___________________________________ D. B.A. ________________________________________ Principal Office address _____ _______________________ City/State/Zip Code ________________________________ Daytime Phone # __________________________________ 2nd 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/Not to exceed $5,000.00 per cause of action $ ____________________________ 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 _______________________ Today's Date American LegalNet, Inc. www.FormsWorkFlow.com 9JD-CC-APP (4/2016) / COMMERCIAL CLAIMS APPLICATION Page 2 of 2 **CERTIFICATION: (UCCA 1803-A Limitation on Filings) (required in all Commercial Claim and Consumer Transaction Cases) Note: The Commercial Claims part will dismiss any case where this certification is not made I hereby certify that no more than five (5) actions or proceedings (including the instant action)pursuant to the commercial claims procedure have been initiated in the Courts of this state during the present calendar month. ______________________________________________ Signature of Claimant _______________________ Date Sworn to before me this_________ day of __________, 20__________ _______________________ Signature of Notary **NOTE: The Commercial Claims Part shall have no jurisdiction over and shall dismiss any case where this certification is not made. __________________________________________________________________ CONSUMER TRANSACTION 9 Consumer Transaction 9 Not Applicable (a Consumer Transaction is a transaction where the money, property or service that is the subject of the transaction is primarily for personal, family or household purposes) CERTIFICATION: (UCCA 1803-A) CONSUMER TRANSACTION 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. _______________________________________________ Signature of Claimant _______________________ Date Sworn to before me this_________ day of __________, 20__________ _______________________ Signature of Notary 9JD-CC-APP American LegalNet, Inc. www.FormsWorkFlow.com (4/2016)