Fillable Form 1.: STATE OF MICHIGAN JUDICIAL DISTRICT AFFIDAVIT (Michigan)

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Form 1.: STATE OF MICHIGAN JUDICIAL DISTRICT AFFIDAVIT (Michigan)

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Approved, SCAO
Form DC 84, Rev. 1/21
MCL 600.8401 et seq., MCR 4.302, MCR 4.303, 50 USC App 3931
Page 1 of 3
Distribute form to:
Court (with instructions)
Defendant (with instructions)
Plaintiff (with instructions)
Return (with proof of service)
STATE OF MICHIGAN
JUDICIAL DISTRICT
AFFIDAVIT AND CLAIM
Small Claims
CASE NO. and JUDGE
Court address Court telephone no.
See additional notice and instructions on page 3.
1.
Plaintiff
Address
City, state, zip Telephone no.
2.
Defendant
Address
City, state, zip Telephone no.
3. A civil action between these parties or other parties arising out of the transaction or occurrence alleged in this
complaint has been previously filed in this court
Court.
It was given case number
and assigned to Judge
.
The action remains is no longer pending.
4. I have knowledge or belief about all the facts stated in this affidavit and I am
the plaintiff or his/her guardian, conservator, or next friend. a partner. a full-time employee of the plaintiff.
5. The plaintiff is an individual. a partnership. a corporation. a sole proprietor.
.
6. The defendant is an individual. a partnership. a corporation. a sole proprietor.
.
7. The date(s) the claim arose is/are
Attach separate sheets if necessary
.
8. Amount of money claimed is $
. (Note: Plaintiff’s costs are determined by the court and awarded as appropriate.
They are not part of the amount claimed.)
9. The reasons for the claim are:
10. The plaintiff understands and accepts that the claim is limited to $6,500 by law and that the plaintiff gives up the rights to
(a) recover more than this limit, (b) an attorney, (c) a jury trial, and (d) appeal the judge’s decision.
NOTICE OF HEARING
For Court Use Only
The plaintiff and the defendant must be in court on
Day
Date
at
Time
at the court address above.
Location
.
Process server’s name
Fee paid: $
Form Instructions
Affidavit and Claim, Small Claims (1/21)
Page 2 of 3
Case No.
11. I believe the defendant is is not mentally competent. I believe the defendant is is not 18 years or
older.
12. I do not know whether the defendant is in the military service. The defendant is not in the military service.
The defendant is in the military service.
Signature
Subscribed and sworn to before me on
Date
.
Deputy clerk/Notary public signature
My commission expires on
.
Name (type or print)
Notary public, State of Michigan, County of
. Acting in the County of
.
This notarial act was performed using an electronic notarization system or a remote electronic notarization platform.
The defendant(s) must be served by
Expiration date
.
Affidavit and Claim, Small Claims (1/21)
Page 3 of 3
Case No.
ADDITIONAL NOTICE AND INSTRUCTIONS
TO BOTH THE PLAINTIFF AND THE DEFENDANT:
• You must bring to the hearing all witnesses, books, papers, and other physical evidence needed to prove or disprove this
claim.
• Before the trial (hearing) starts, you have the right to
1. remove the case to the general civil division of the district court, or
2. have the case heard by a district court judge (if the hearing is scheduled before an attorney magistrate). If the case
is heard by an attorney magistrate, you may appeal to the district judge within 7 days after the trial.
• If the case is tried in the small claims division, you give up the right to an attorney, to a jury trial, and to appeal the judge's
decision.
If you require accommodations to use the court because of a disability or if you require a foreign language interpreter to help
you fully participate in court proceedings, please contact the court immediately to make arrangements.
TO THE DEFENDANT:
• The affidavit and claim you have just received means you are being sued in the small claims division of the district court.
• The court is being asked to decide a matter that the plaintiff says is your obligation and responsibility.
• If you wish to deny this claim or arrange terms of payment, you must make your request by appearing at the date, time,
and place stated in the notice of hearing on the front of this form.
• If you do not appear at the date, time, and place stated, a default judgment may be entered against you for the amount
stated in item 8, including the costs of this action.
• If the dispute is settled before or at the hearing, you may have to pay the plaintiff's costs.
• In case a judgment is entered against you at the hearing, you should be prepared to pay the amount stated in item 8,
including the costs of this action, or to make arrangements for installment payments.
Affidavit and Claim, Small Claims (1/21) Case No.
CERTIFICATE / AFFIDAVIT OF SERVICE / NONSERVICE
TO PROCESS SERVER: You are to serve this affidavit and claim no later than 7 days before the hearing date. You must
make and file your return with the court clerk. If you are unable to complete service, you must return this original and all
copies to the court clerk.
PROOF OF SERVICE
I served personally by registered or certified mail (copy of return receipt attached) a copy of the
affidavit and claim on:
I have attempted to serve the affidavit and claim and have been unable to complete service on:
Defendant’s name Date and time of service
Place or address of service
Attachments (if any)
I declare under the penalties of perjury that this return of service has been examined by me and that its contents are true
to the best of my information, knowledge, and belief.
Signature
Service fee
$
Miles traveled Fee
$
Incorrect address fee
$
Miles traveled Fee TOTAL FEE
$
$
Name (type or print)
Title (if applicable)
Note: If documents are served by someone other than a sheriff, deputy sheriff, or other person listed in MCL 600.1910(b), this return must be notarized.
Subscribed and sworn to before me on
Date
.
Deputy clerk/Notary public signature
My commission expires on
.
Name (type or print)
Notary public, State of Michigan, County of
. Acting in the County of
.
This notarial act was performed using an electronic notarization system or a remote electronic notarization platform.
I acknowledge that I have received service of the affidavit and claim, together with
Attachments
on
Date and time
Signature
on behalf of
MCR 2.105
ACKNOWLEDGMENT OF SERVICE
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Form 1.: STATE OF MICHIGAN JUDICIAL DISTRICT AFFIDAVIT (Michigan)

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Completed 21 March 2022

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