IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY Small Claims Department ) ) ) ) ) ) ) ) ) ) ) ) Case No: ____________________ Plaintiff (Inmate ID #, if applicable, _____________) v. SMALL CLAIM AND NOTICE OF SMALL CLAIM Filing fee at ORS 46.570 Interpreter needed: Spanish other: _______________ Defendant Defendant is a public body PLAINTIFF ( Name Street City / State / Zip Phone County Additional on attached page) Russian DEFENDANT ( Additional on attached page) Name (enter Registered Agent, if necessary, on next page) Street (do not use a P.O. Box) City / State / Zip Phone County I, Plaintiff, claim that on or about (date) sum of $_____________ because , the above-named defendants owed me the , and this amount is still due. I have paid (or will pay): filing fees of $_____________ and service costs of $____________ Claim $______________ + Fees $______________ +Costs $______________ TOTAL $______________ Form 15.010.1a ­ SMALL CLAIM AND NOTICE OF SMALL CLAIM ­ UTCR 15.010(1)(a) (Revised 8-1-14) Case No. 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 ________________________________ Email address* Plaintiff Signature Plaintiff Name (print) *Some courts communicate with parties by email. By providing my email address I consent to receive notifications from the court by email instead of or in addition to other methods. I understand that if my email changes or if I choose to withdraw consent, I must notify the court in writing. DEFENDANT'S REGISTERED AGENT: Name Street (do not use a P.O. Box) City / State / Zip Phone County Form 15.010.1a ­ SMALL CLAIM AND NOTICE OF SMALL CLAIM ­ UTCR 15.010(1)(a) (Revised 8-1-14) Case No. 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) 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. COURT NAME / ADDRESS / PHONE # > > > 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. Form 15.010.1a ­ SMALL CLAIM AND NOTICE OF SMALL CLAIM ­ UTCR 15.010(1)(a) (Revised 8-1-14) Case No. American LegalNet, Inc. www.FormsWorkFlow.com