CIVIL COURT OF THE CITY OF NEW YORK APPLICATION FOR A SUMMONS PARTIES PLAINTIFF: (Your name and complete address, including your apartment number and te lephone number.) [NOTE: If the claim is based on an auto accident, the claim must be Owner against Owner]. DEFENDANT(S): (The full legal name and street address (no box number) of the party( ies) you are suing. Indicate whether you are suing this party as a person or a business.) [NOTE: If you are suing a business, indicate whether it is apartnership, a corporation or an individual with a business certificate. This information can be obtained in the CountyClerks Office in the county in which the business is located. Failure t o check this information may result in a judgmentwhich cannot be executed.] CLAIM REASON FOR CLAIM: Damage cause to: automobile person property other than automobile Failure to provide: repairs proper service goods ordered Failure to return: security property deposit money Failure to pay for: wages services rendered insurance claim money loaned rent commissions goods sold and delivered Breach of: contract lease Loss of: luggage property time from work use of property Returned: check (bounced) merchandise (not reimbursed) Other: (Be brief) DETAILS OF CLAIM: Amount of Claim: (Limit $25,000 for each Cause of Action) $ Date of Occurrence: Place of Occurrence: If Car Accident: YOUR license plate # DEFENDANTS license plate # Identifying Number(s): (Receipt #, Claim #, Account #, Policy #, Ticket #, etc.) X Date Signature of Plaintiff CIV-GP-59-i (Revised 7/04) American LegalNet, Inc. www.USCourtForms.com