IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR LINCOLN COUNTY Small Claims Department ______________________________________ ) ) ______________________________________ ) Plaintiff ) Inmate ID #, if applicable, ___________________ ) v. ) ) Case No: __________________ SMALL CLAIM AND NOTICE OF SMALL CLAIM ______________________________________ ) ) ______________________________________ ) Defendant ) Defendant is a public body Filing fee at ORS 46.570 PLAINTIFF ( Name Street Additional on attached page) DEFENDANT ( Name Additional on attached page) ______________________________________ ______________________________________ ______________________________________ ______________________________________ Defendant's Registered Agent: ______________________________________ ______________________________________ City/State/Zip Street (do not use a PO Box) ______________________________________ ______________________________________ Phone County City/State/Zip ______________________________________ Phone County I, Plaintiff, claim that on or about (date) $__________because ________________, the above-named defendants owed me the sum of _____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________________________, and this amount is still due. I have paid (or will pay): Filing fees of $_________ And service costs of $________ Claim $_________ $_________ $_________ + Fees + Costs TOTAL $_________ DECLARATION OF BONA FIDE EFFORT I, Plaintiff, have made a bona fide effort to collect this claim from the defendants before filing this claim with the court clerk. I hereby declare that the above statements are true to the best of my knowledge and belief, and that I understand they are made for use in court and I am subject to penalty for perjury. _________________________ Date ______________________________ Plaintiff Signature ______________________________ Revised 8/2012 Plaintff Name (print) American LegalNet, Inc. www.FormsWorkFlow.com