Lima Municipal Court 109 N Union St Lima, Ohio 45801 __________________________ __________________________ Address Zip Code SMALL CLAIM COMPLAINT ____________________ Municipal Court ______________________ County Court ___________ Area ___________ District ____________________________, Ohio __________________________ Tele. No. Plaintiff, vs. __________________________ __________________________ Address Zip Code __________________________ Tele. No. Case No. _____________________ Defendant, TO THE CLERK: Please take notice that a claim is hereby filed against the above defendant(s) and request that he/she (they) be summoned to appear in Court to answer same. STATEMENT OF CLAIM [ ] ACCOUNT ­ EXHIBIT A ATTACHED AND MADE A PART HEREOF [ ] WAGES _________ [ ] OTHER ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Wherefore plaintiff prays judgment against defendant in the sum of $___________, plus interest from the _______ day of ______________, 20____, at the rate of ___________% and costs. STATE OF OHIO ) AFFIDAVIT OF COMPLAINANTS CLAIM ss. COUNTY OF ______________ ) __________________________, being first duly sworn, on oath states that _______________________ the Plaintiff in the above entitled cause; that said cause is for the payment of money that the nature of plaintiff's demand is as stated, and that there is due to plaintiff from defendant the amount stated above; defendant(s) (is are) not now in the military or naval service of the United States. __________________________ Subscribed and sworn to before me this _______ day of _____________, 20____. __________________________ Clerk, Deputy Clerk, Notary Public American LegalNet, Inc. www.FormsWorkFlow.com