(FOR OFFICE USE ONLY) INSTRUCTIONS: CIVIL COURT OF THE CITY OF NEW YORK Place only ONE letter or number in each space SMALL CLAIMS PART and leave a blank space between words. STATEMENT OF CLAIM I. CLAIMANTS INFORMATION (Your) LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS (NO P.O. BOX) BOROUGH, CITY, STATE ZIP TOWN OR VILL. OTHER INFO [Doing Business As] [In Care Of] [Attention To] Circle One PHONE NO. CERTD # II. DEFENDANTS INFORMATION* (Their) LAST NAME (or Full Business Name) COA CODE FIRST NAME MIDDLE INITIAL ADDRESS CLAIM AMT. (NO P.O. BOX) $ BOROUGH CITY, STATE N Y ZIP FEE TOWN OR VILL. STANDARD FEE OTHER INFO CLAIMANT V. DEFENDANT[Doing Business As] [In Care Of] PHONE NO. [Attention To] Circle One NO FEE DEFENDANT V. THIRD PARTY III. CLAIM CLAIMANT V. ADDL DEFENDANT POSTAGE ONLY (Maximum $5, 000) Date of Occurrence or Transaction:Amount Claimed: $ WAGE CLAIM TO $300 Place of occurrence, if Auto Accident LANGUAGE PRIMARY REASON FOR CLAIM (Check One): Damage caused to: automobile other personal property real property person DATE DATA ENTERED Failure to provide: proper repairs proper services proper merchandise goods paid for Failure to return: security property deposit money loaned Failure to pay: salary for services rendered insurance claim DATE NOTICES MAILED rent commissions for goods sold and delivered Breach of. contract lease warranty agreement CASE TYPE: Loss of: luggage property time from work use of property MULTI DFT CTR/CLM Returned: check (bounced) check (stopped) Other: (Be brief) 3 PARTY CRS/CMPLT FIRST DATE IDENTIFYING NUMBER(S) - (Receipt #, Claim #, Account #, Policy #, Tic ket #, License #, Plate #(s)) DAY COURT Todays Date Signature of Claimant or Agent STATUTORY OTHER * DEFENDANTS NAME: The legal name will be required in order to obtain an enforceable judgment. If th e Defendant is a business, its full and correct business name should he obtained from the Office of the County Clerk in the county in which the business is loca ted or check on the following website: www.dos.state.ny.us. DEFENDANTS ADDRESS: YOU must indicate the proper street address of the Defendant. A Post Office Box is not acceptable. CIV-SC-50 (Revised 7/05) NOTE: If the Claim is a result of an automobile accident, the Claim must be OWNER against OWNER. American LegalNet, Inc. American LegalNet, Inc. www.USCourtForms.com www.USCourtForms.com