GRAYS HARBOR COUNTY DISTRICT COURT, DEPT. 2 2109 Sumner Ave., Room 201, Pearsall Building, Aberdeen, WA 98520 (360) 532-7061 Name(s): _______________________________ _______________________________________ Street Address:___________________________ PO Box:________________________________ City:___________________________________ State & Zip:_____________________________ Phone number:___________________________ Plaintiff(s), v. Name(s):_______________________________ _______________________________________ Street Address:___________________________ PO Box:________________________________ City:___________________________________ State & Zip:_____________________________ SMALL CLAIMS DEPARTMENT Case No._______________ Notice of Claim Phone number:________________________ Defendant(s). TO THE DEFENDANT(S) ABOVE NAMED: You are notified to be and appear at Grays Harbor County District Court (Dept. 2) located at 2109 Sumner Avenue, Room 201, Pearsall Building, Aberdeen, Washington, on the _ day of , at 9:00 a.m., for pre-trial. You are to bring with you any and all papers, contracts and proof needed by you to establish or defend this claim. You are further notified that if you fail to personally appear as directed, a Judgment may be entered against you for the amount claimed, plus plaintiff's costs of filing and service of the claim upon you. Plaintiff must also appear if a judgment is to be entered. If Plaintiff fails to appear, the claim may be dismissed. All claims remaining in dispute after pre-trial will be referred to mediation services prior to trial. If the claim is not resolved after attempting mediation, a trial date will be set, at which time you may request your witnesses to appear. An informational pamphlet about Small Claims Cases is available free at the court office. Dated: , (To be filled in by court staff) . Mallin Shelton, Court Administrator By Notice of Claim in Small Claims Department of District Court (7/2007) - Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com STATEMENT OF CLAIM The Plaintiff (s) above named claims that the Defendant(s) above named owes the Plaintiff(s) the the sum of $ The amount owed is for: , which became due and owing on [Date] . ? Faulty Workmanship ? Merchandise ? Wages ? Loan ? Other Explain reason for claim ? Auto Damages-Date of Accident ? Rent ? Property Damage ? Return of Deposit I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at _______________________, [City] ____________ [State] on ____________________ [Date]. Signature Print or Type Name Notice of Claim in Small Claims Department of District Court (7/2007) - Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com