STATE OF SOUTH DAKOTA COUNTY OF IN MAGISTRATE COURT JUDICIAL CIRCUIT PLAINTIFF'S STATEMENT OF SMALL CLAIMS Plaintiff Names or Business Name vs. SMC Case #: Defendant Names or Business Name Describe the basis for your claim: (use additional sheet if necessary) Principal Interest Subtotal Filing Fees Plaintiff's Total (exclude interest and filing fees) Small Claims Fee Calculator http://ujs.sd.gov/Self_Help_Center/smallclaimscalc Sheriff Service only � no certified mail Sheriff/Personal Service requested if certified mail returned undelivered *Additional fees charged for service options listed above. It's the plaintiff's responsibility to contact the Sheriff's Office or process server for fee amounts and to file the Return of Service. /S/ Plaintiff's Signature 1 American LegalNet, Inc. www.FormsWorkFlow.com Date UJS-008 04/2016