SUFFOLK COUNTY DISTRICT COURTCOMPLAINT FORM COURT DATEINDEX NO. TIME & DISTRICTTYPE OR PRINT IN BLACK INK CHECK ONE TYPE OF CLAIM: SMALL CLAIM COMMERCIAL CLAIM CONSUMER TRANSACTIONCHECK ONE SESSION: DAY CO URTO NIGHT COURT DATE MAILED PLAINTIFF'S NAME AND ADDRESS If plaintiff is a business you must enter your true business name.Last Name, First Name or True Business NameStreet Address (PO Box alone is not acceptable)City, State, ZIPTelephone Number: DEFENDANT'S NAME AND ADDRESS If defendant is a business you must enter its true business name.Last Name, First Name or True Business NameStreet Address (PO Box alone is not acceptable)City, State, ZIPTelephone Number: Additional PlaintiffAdditional DefendantLast Name, First Name or True Business NameStreet Address (PO Box alone is not acceptable)City, State, ZIPTelephone Number: Additional PlaintiffAdditional DefendantLast Name, First Name or True Business NameStreet Address (PO Box alone is not acceptable)City, State, ZIPTelephone Number: If you need to list more than four parties, submit additional pages as needed, and check here: CHECK ONE CAUSE OF ACTION: (5) PERSONAL INJURIES (40) MONIES DUE (50) PAYMENT OF LOAN (10) PROPERTY DAMAGE (70) REFUND ON DEFECTIVE MERCHANDISE (15) LOSS OF PERSONAL PROPERTY (80) REFUND ON DEFENDANT'S DEFECTIVE WORK,LABOR AND/OR SERVICES (20) GOODS SOLD AND DELIVERED (25) BREACH OF CONTRACT OR WARRANTY (85) OTHER CAUSE OF ACTION (35) WORK, LABOR AND SERVICESBRIEFLY STATE DETAILS OF YOUR CLAIM:TOTAL AMOUNT OF DAMAGES: $ The undersigned acknowledges that he/she has been advised that supporting witnesses, account books, receipts and otherdocuments required to establish the claim herein must be produced at the hearing. The undersigned further certifies to the best ofhis/her knowledge, the defendant is not in the military service. If this is a complaint filed as a Commercial Claim (UDCA 2471803-A), the undersigned hereby certifies that no more than five (5)actions or proceedings (including the instant action) pursuant to the commercial claims procedure have been initiated in the courtsof this state during the present calendar month.THIS FORM MUST BE SIGNED IN THE PRESENCE OF A COURT CLERK OR NOTARY DATED:PLAINTIFF AS AUTHORIZED AGENT OF PLAINTIFFCLERK OR NOTARY AS PARENT AND NATURAL GUARDIANDC-283 (10/03) American LegalNet, Inc. www.FormsWorkFlow.com