IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY SMALL CLAIMS DEPARTMENT (Please type or print legibly) Plaintiff(s): Filing Fee: ___________ Service Fee: ___________ 1.)______________________________ 2.) ______________________________ _________________________________ Mailing address CASE NUMBER: _____________ _________________________________ City State Zip code (_____)____________________________ Phone number CLAIM AND NOTICE OF CLAIM vs. Defendant(s): 1.)______________________________ 2.) ______________________________ _________________________________ Mailing address _________________________________ City State Zip code (_____)____________________________ Phone number I, Plaintiff, claim that on or about _______________________, _______, the above named Defendant(s) owed me the sum of $_____________, and this sum is still owing for (reason): _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. I state that I have made a bona fide effort to collect this claim before filing with the Court. DATED: __________________ ______________________________ Plaintiff ***************************************************************** NOTICE TO DEFENDANT: READ ALL PAGES OF THIS DOCUMENT CAREFULLY I certify that the foregoing is a true copy of the claim filed against you. Trial Court Administrator DATED: ____________________ Public SmClaims Notice of Claim By: _________________________ Clerk Page 1 of 2 8/28/10 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO DEFENDANT: READ THESE PAPERS CAREFULLY!! Within 14 DAYS after receiving this notice you MUST do ONE of the following things: Pay the plaintiff the amount of claim plus filing fees and service fees*; OR Demand a hearing; OR Demand a jury trial *You will have to contact the plaintiff to determine amount of fees which were paid. If you choose to demand a hearing or a jury trial, you MUST FILE A DEFENDANT’S ELECTION with the court within 14 DAYS of receiving this notice. If you fail to do one of the above within 14 DAYS after receiving this notice, then upon written request from the plaintiff, the clerk of the court will enter a default judgment against you for the amount claimed plus filing fees and service expenses paid by the plaintiff, plus a prevailing party fee. If you have questions about the small claims court filing procedures after reading this notice, you may contact the clerk of the court, however, the clerk cannot give you legal advice. Defendant filing fees: Please see Jackson County Court fee schedule at www.courts.oregon.gov/jackson/ JACKSON COUNTY CIRCUIT COURT 100 S. OAKDALE AVENUE MEDFORD, OR 97501-3127 541.776.7171 ext. 581 Public SmClaims Notice of Claim Page 2 of 2 8/28/10 American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY SMALL CLAIMS DEPARTMENT (Please type or print legibly) Plaintiff(s): 1.) _____________________________ CASE NUMBER: ________________ 2.) _____________________________ NOTICE OF DEFENDANT’S ELECTION vs. Defendant(s): 1.) _____________________________ 2.) _____________________________ PART I: Claim received: On (date)___________________ I was served a notice of claim under ORS 46.445 where the above-named plaintiff made a claim against me in the above-entitled court:  In the amount of $__________________  For the following property ___________________________________________________ PART II: Defendant’s Election. (Note 1: Each defendant listed above must sign and file a separate notice of defendant’s election. Note 2: A husband and wife may file a joint election.) I elect to respond under ORS 46.455 as follows: 1._____ I ADMIT the plaintiff’s claim. I will pay the money or return any property claimed, together with the filing fees and service fees, directly to the plaintiff and mail proof of that delivery and payment to the court within 14 calendar days of the date the claim was served on me. 2._____ I DENY the claim and demand a Small Claims hearing. Enclosed are court fees of $________ (see Part III below). 3._____I DENY the claim, demand a Small Claims hearing and wish to file a COUNTERCLAIM arising out of the same transaction or occurrence that is the subject matter of the plaintiff’s claim. Enclosed are court fees of $______ (See Part III below). I claim that the plaintiff owes me $______________ because:_______________________________________________________________________________ ____________________________________________________________________________ 4._____I DENY the claim and demand a JURY TRIAL. (Only if the claim exceeds $750.00.) I enclose court fees of $__________ (See Part III below). This choice requires the plaintiff to file a formal complaint in circuit court. If the plaintiff does not file a complaint, I ask that my JURY FEE be refunded to me. The plaintiff can mail a copy of the formal complaint to me at: _________________________________________________________________________________ Street address City State Zip Code PART III: Fees. I understand that Court fees are based on the amount indicated in Part I, above, and may include other fees depending on how I respond in Part II above. I must contact the court for the appropriate fee amount. If the appropriate fees are not enclosed, the form will not be accepted for filing and may result in a default judgment against me. PART IV: Signature . I have read and understand the above. I have chosen one of the four options and have enclosed the appropriate fees. DATED:________________ SIGNED______________________________ ______________________________ Print name Mailing address: Street/PO Box City State Zip code _______________________________ Phone Public SmClaims Notice Defendant Election Page 1 of 1 8/28/10 American LegalNet, Inc. www.FormsWorkFlow.com