STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT SMALL CLAIMS NOTICE OF SUIT - COMPLAINT Civil Action File Number: Attorney for the Plaintiff Address of the Plaintiff's Attorney or the Plaintiff Plaintiff Defendant Address of the Defendant Murray Judicial Complex 2nd Division District Court 45 Washington Square Newport, Rhode Island 02840-2913 (401) 841-8350 McGrath Judicial Complex 4th Division District Court 4800 Tower Hill Road Wakefield, Rhode Island 02879-2239 (401) 782-4131 Noel Judicial Complex 3rd Division District Court 222 Quaker Lane Warwick, Rhode Island 02886-0107 (401) 822-6750 Garrahy Judicial Complex 6th Division District Court One Dorrance Plaza Providence, Rhode Island 02903-2719 (401) 458-5400 The Plaintiff(s) claims that the Defendant(s) owes $_____________ plus the cost of suit for the following reasons: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DC-SC-1 (revised October 2014) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT SMALL CLAIMS NOTICE OF SUIT - COMPLAINT Proof of Claim and Military Service Affidavit The Plaintiff(s), being duly sworn, upon information and belief deposes and say: 1. That the Defendant(s) owes $____________________ as set forth above. 2. That the Defendant(s) is not an infant or an incompetent, and presently resides at _____________________________________________________________________________; and [PLEASE CHECK THE APPLICABLE BOX] That the Defendant(s) was not at the commencement of the above-entitled action, nor is now, in the "Military Service" of the United States as defined in the Servicemember's Civil Relief Act, 50 App. U.S.C. § 521, nor is the Defendant(s) an American citizen serving with the forces of a United States ally or a reservist/draftee called to active duty; or That despite exercising due diligence, the Plaintiff(s) lacks sufficient information and has been unable to determine whether the Defendant(s) is in the "Military Service." Waiver of Right of Appeal The Plaintiff(s) hereby waives the right to appeal pursuant to G.L. 1956 § 10-16-4(b). ________________________________ Signature of the Plaintiff State of _______________________ County of _____________________ On this ________ day of ________________, 20____, before me, the undersigned notary public, personally appeared ____________________________________ personally known to the notary or proved to the notary through satisfactory evidence of identification, which was _____________________________________________, to be the person who signed the preceding or attached document in my presence, and who swore or affirmed to the notary that the contents of the document are truthful to the best of his or her knowledge. Notary Public: ____________________________________ My commission expires: ________________________ Notary identification number: _______________ DC-SC-1 (revised October 2014) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT SMALL CLAIMS NOTICE OF SUIT - COMPLAINT Civil Action File Number: Attorney for the Plaintiff Address of the Plaintiff's Attorney or the Plaintiff Plaintiff Defendant Address of the Defendant Continuation page if needed. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DC-SC-1 (revised October 2014) American LegalNet, Inc. www.FormsWorkFlow.com