IN THE DISTRICT COURT OF JEFFERSON COUNTY, WASHINGTON 360 385 9135 NOTICE OF SMALL CLAIM PLAINTIFFS NAME_____________________________ SMALL CLAIMS #_______________ ADDRESS______________________________________ HOME PHONE__________________ _______________________________________________ WORK PHONE__________________ vs DEFENDANTS NAME___________________________ ADDRESS______________________________________ _____________________________________________ HOME PHONE____________________ WORK PHONE____________________ STATEMENT OF CLAIM I, above owes me the sum of $ , the undersigned plaintiff, declare that the defendant named , which became due and owing on [Date]. The amount owed is for: __________________________________________________________________ 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 YOU ARE HEREBY NOTIFIED that the above named Plaintiff has filed a claim against you amounting to $ ; the reasons for which are stated below. YOU ARE HEREBY FURTHER NOTIFIED to be and appear at Jefferson County District Court 1820 Jefferson Street Port Townsend, Washington on ______________________, 20_____ at ______________ a.m../p.m. for  MEDIATION  TRIAL. You are to bring with you any and all papers, contracts and proof needed by you to establish or defend this claim. At the time of trial you must bring any witnesses who will testify on your behalf. 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. If this claim is settled prior to the hearing date, the parties must notify the Court immediately, in writing. Clerk American LegalNet, Inc. www.USCourtForms.com