IN THE DELAWARE MUNICIPAL COURT Small Claims Division Complaint DELAWARE MUNICIPAL COURT JUSTICE CENTER 70 NORTH UNION STREET DELAWARE, OHIO 43015 SMALL CLAIMS DIVISION (740) 368-1550 FAX NO. (740) 368-1583 www.municipalcourt.org NAME OF PLAINTIFF CASE NO. STREET ADDRESS INSTRUCTIONS: Please type or print all information on the form. If additional space is needed, lined paper may be attached. Give a short, accurate description of the basis for the complaint in the space provided below. Attach any documents upon which the complaint is based. Failure to properly complete the complaint form may result in dismissal of the complaint. CITY, STATE, ZIP CODE TELEPHONE NO./FAX VS. NAME OF DEFENDANT (1) NAME OF DEFENDANT (2) STREET ADDRESS STREET ADDRESS CITY, STATE, ZIP CODE CITY, STATE, ZIP CODE TELEPHONE NO./FAX TELEPHONE NO./FAX STATEMENT OF COMPLAINT The undersigned being duly sworn, on oath, states that he/she is the above-named Plaintiff in this action and has filed this complaint against the above-named Defendant(s) seeking money damages in the amount of $ plus interest as provided by law plus costs on the following basis (failure to provide a description below may result in dismissal): SIGNATURE OF PLAINTIFF/PLAINTIFF’S AGENT SUBSCRIBED AND SWORN BEFORE ME THIS PRINTED/TYPED NAME OF PLAINTIFF/PLAINTIFF’S AGENT DAY OF ,2 . Clerk, Deputy Clerk, Notary Clerk FORM A rev 0504 American LegalNet, Inc. www.USCourtForms.com