INSTRUCTIONS FOR COMPLETING "AFFIDAVIT AND CLAIM, SMALL CLAIMS"
Please print neatly.
Items1through12mustbecompletedbeforeyourclaimcanbeledwiththecourt.Pleasereadtheinstructionforeachitem.
Thenllinthecorrectinformationforthatitemontheform.
Writeinthenames,addresses,andtelephonenumbersoftheplaintiandthedefendant.Theplaintiisthe
nameofthepersonsuingandmaybesomeoneotherthanyou.Iftheplaintiisabusiness,specifyboththe
legal name and any assumed name in which the business is being conducted. The defendant is the person
being sued. If you are suing a business, state its legal name if you know it. If you do not know its legal name,
state the name the business was using to conduct business. If there is more than one defendant, write the
words "et al." after the name of the defendant and write the additional names and addresses on a separate
sheet of paper.
Checktheboxthatistrue.Ifanothercivilcasewasledthatinvolvedtheplaintianddefendantregardingthe
sameproblemstatedinthisclaim,writethenameofthecourtwherethecasewasled,thecasenumber,and
thenameofthejudgeassignedtohearthatcase.Checktheboxwhetherthatcaseisorisnotstillpending.
Apersonotherthantheplainticancompleteandsignthisform.Readpage3andthenchecktheboxthat
bestdescribesyourrelationshiptotheplainti.Ifyouaretheplainti,checkthebox"plainti."Ifyouarea
partner and you are suing for the partnership, check the box "a partner." If you are a full-time employee of
theplaintiandaresuingfortheplainti,checkthebox"afull-timeemployeeoftheplainti."
Theplainticanbeeither:1)anindividual,2)apartnership,3)acorporation,4)asoleproprietor(aprivate
businessownerwithoutapartner),or5)anotherorganization.Checktheboxthatbestdescribestheplainti,
and if applicable, complete the blank for "other."
The defendant can be either: 1) an individual, 2) a partner in a business partnership, 3) a corporation, 4) a sole
proprietor(aprivatebusinessownerwithoutapartner),or5)anotherorganization.Checktheboxthatbest
describes the defendant, and if applicable, complete the blank for "other." If there is more than one defendant,
you will need to provide this information for each defendant.
Writeinthedatethatthedisputeoccurred.Forexample,ifthedefendantowedmoneyonacertaindateand
didnotpayonthatdate,printthatdatehere.Or,ifthedefendantdamagedsomethingthatbelongedtoyou,
print the date that the damage occurred.
Writeintheamountofthemoneyowedorthatyoubelieveisowedtocoveranydamageevenifitismorethan
$6,000. If the amount is more than $6,000 and the case is decided in the small claims division of the district
court,theplaintigivesuptherighttoanyamountover$6,000.Theplainticannotleanotherformtogeta
judgmentforthebalance.Iftheplaintiwantsajudgmentforanamountover$6,000andtheclaimisfor
$25,000orless,alawsuitmustbeledinthecivildivisionofthedistrictcourt.
Brieyexplainthereasonsfortheclaim.Includewhathappenedtocausethedispute.
Make sure that you understand and agree with this statement.
Checktheboxesthataremostaccurate.
Checktheboxthatismostaccurate.
DO NOT SIGN YOUR NAME until you are standing in front of a notary or the clerk of the court.
DO NOT WRITE IN THE SECTION AFTER ITEM 12. The notary public or clerk of the court will complete this section.
Fileyouradavitandclaimwiththecourt.Theclerkofthecourtwillentertheexpirationdateandcompletethenotice of
hearing. See page 4 of this packet for details.
• Readpages3through5ofthisbookletfordetailsonlingandservingthisform.
You must read this booklet for directions on the legal process.
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