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Address v. (Kansas Judicial Council)

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02/2022 KSJC 1
IN THE ____________________ JUDICIAL DISTRICT
DISTRICT COURT OF ____________________ COUNTY, KANSAS
______________________________, Plaintiff
______________________________
______________________________
Address
CASE NO. ______________
v.
______________________________, Defendant
______________________________
______________________________
Address
Pursuant to Chapter 61 of Kansas Statutes Annotated
SMALL CLAIMS PETITION
Under K.S.A. 61-2701, et seq.
1. Statement of claim:
I, ______________________, have read the instructions for completing this form and
assert this claim against ______________________, Defendant:
Briefly state the facts of this dispute.
2. Demand for judgment (What do you want the Court to order?):
Based on the claim stated above, I demand this judgment against Defendant:
A. Payment of $__________, plus interest, costs, and any damages awarded under K.S.A.
60-2610.
B. Recovery of this personal property, plus costs:
This property has an estimated value of $__________.
02/2022 KSJC 2
I, ______________________, declare under penalty of perjury that, to the best of my knowledge
and belief, the claim stated above against Defendant (including the estimated value of any property
I am asking to recover) is a just and true statement, not including any valid claim or defense
Defendant may have.
___________________________________
Signature of Plaintiff
Printed Name: ___________________________________
Address: ________________________________________
City, State Zip: __________________________________
Phone #: _______________________________________
Fax # (if you have one): ____________________________
Email address: ___________________________________
02/2022 KSJC 3
Instructions to Plaintiff:
A. State the facts of your dispute against Defendant by writing in the space provided in
paragraph 1. Be clear and concise.
B. Your total claim against defendant may not exceed $4,000, not including
interest, costs, and any damages awarded under K.S.A. 60-2610.
C. If you do not come to the hearing, your case might be dismissed. If Defendant files a
claim against you and you fail to appear, a judgment might also be entered against
you on Defendant’s claim.
D. You must write your demand for judgment in paragraph 2A, 2B, or both of the petition
above.
E. Except as provided by law, neither you nor the defendant can have an attorney with
you during the hearing.
F. You may not file more than 20 small claims under the small claims procedure act in
this Court during any calendar year.
G. After completing this form, you must sign it under penalty of perjury.
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Address v. (Kansas Judicial Council)

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Completed 15 March 2022

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