Small Claim and Notice of Small Claim Page 1 of 3 (Aug 2019) IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF Small Claims Department Case No: Plaintiff ( Inmate S ID #, if applicable, ) SMALL CLAIM AND v. NOTICE OF SMALL CLAIM Filing fee at ORS 46.570 Subject to UTCR 5.180(3) Defendant Defendant is a public body Subject to ORS 646A.670(1) and UTCR 5.180(2) PLAINTIFF ( Additional on attached page) DEFENDANT ( Additional on attached page) Name Name (enter Registered Agent, if necessary, on next page) Street Street (do not use a P.O. Box) City / State / Zip City / State / Zip Phone County Phone County I need an interpreter: Spanish Russian other: I, Plaintiff, claim that on or about (date) , the above-named defendants owed me the sum of (or property valued at) $ because , and this amount is still due. I have paid (or will pay): filing fees of $ and service costs of $ Claim $ + Fees $ +Costs $ TOTAL $ American LegalNet, Inc. www.FormsWorkFlow.com Small Claim and Notice of Small Claim Page 2 of 3 (Aug 2019) DECLARATION OF GOOD FAITH EFFORT I, Plaintiff, have made a good faith effort to collect this claim from the defendants before filing this claim with the court clerk. (Describe your efforts): If this case is subject to ORS 646A.670(1) (see the box at the top of page 1) See the Oregon Judicial Department website for information about debt collection cases: www.courts.oregon.gov/debtcollection ORS 646A.670(1) and UTCR 5.180. A completed Consumer Debt Collection Disclosure Statement is attached and incorporated into this pleading as required by UTCR 5.180(2)(iii). I hereby declare that the above statements are true to the best of my knowledge and belief. I understand they are made for use in court and I am subject to penalty for perjury. Date Plaintiff Signature Plaintiff Name (print) DEFENDANT222S REGISTERED AGENT: Name Street (do not use a P.O. Box) City / State / Zip Phone County American LegalNet, Inc. www.FormsWorkFlow.com Small Claim and Notice of Small Claim Page 3 of 3 (Aug 2019) 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 # > > > Defendant222s 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) $ You can fill out and file your Response online at www.courts.oregon.gov/iforms . If you have questions about filing procedures, go to www.courts.oregon.gov . 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. American LegalNet, Inc. www.FormsWorkFlow.com