IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF MULTNOMAH Small Claims Department _______________________________________ Name (Plaintiff)(s) _______________________________________ Plaintiff Address CASE NO. SMALL CLAIM AND NOTICE OF SMALL CLAIM FILING FEE AT ORS 46.570 Interpreter needed: Spanish Russian _______________________________________ City / State / Zip _______________________________________ Telephone County other: _______________ (Inmate ID #, if applicable, ___________) v. ___________________________________ ___________________________________ Defendant(s) Defendant is a public body Name and address of defendant(s) for service (enter Registered Agent, if necessary, on the next page): Name (Defendant) Street (do not use a P.O. Box) City / State / Zip Telephone County Name (Defendant) Street (do not use a P.O. Box) City / State / Zip Telephone County I, Plaintiff, claim that on or about (date) ______________, the above-named defendant(s) owed me the sum of $_____________ because _______________________________________________________ , and this amount is still due. Claim $______________ + Fees $______________ +Costs $______________ TOTAL $______________ 05-01 (11/13) Small Claim and Notice of Small Claim Page | 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 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 Plaintiff Name (print) DEFENDANT'S REGISTERED AGENT: Name Street (do not use a P.O. Box) City / State / Zip Phone County 05-01 (11/13) Small Claim and Notice of Small Claim Page | 2 of 3 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 in writing: Pay the claim plus filing fees and service expenses paid by plaintiff (send payment directly to the plaintiff, not to the court) and submit proof of that payment to the court OR Demand a hearing and pay the fee required (below) OR Demand a jury trial and pay the fee required (below). This option is available only if amount claimed is more than $750. If you fail to do one of the above within 14 DAYS* after you get this notice, the plaintiff may ask the court to enter a judgment against you. The judgment will be for the amount of the claim, plus filing fees and service costs paid by the plaintiff, plus a prevailing party fee. If you are not able to respond in time because you are in active military service of the United States, talk to a legal advisor about the Servicemembers Civil Relief Act. Multnomah County Courthouse 1021 SW 4th Ave, Rm 210 Portland, OR 97204 (503) 988-3022 East County Courthouse 18480 SE Stark Street Portland, OR 97233 (503) 988-3199 Defendant's Filing Fees (must be filled in by the PLAINTIFF): (1) To demand a hearing if the amount claimed is $2,500 or less (2) To demand a hearing if the amount claimed is more than $2,500 (3) To demand a jury trial (only if amount claimed is over $750) $ ______ $ ______ $ ______ If you have questions about filing procedures, go to www.courts.oregon.gov for information and instructions, or you may contact the court clerk. The clerk cannot give you legal advice about the claim. *NOTE: If the plaintiff is an inmate (ORS 30.642) AND the defendant is a government agency or other public body (ORS 30.260), the defendant must respond within 30 days after receiving this Notice. 05-01 (11/13) Small Claim and Notice of Small Claim Page | 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com