SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
Civil Division – Small Claims and Conciliation Branch
510 4
th
Street, N.W., Court Building B, Room 120, Washington, D.C. 20001
Telephone Number: (202) 879-1120 Website: www.dccourts.gov
Case No.: ______________________________
______________________________________ ______________________________________
Plaintiff(s) Defendant(s)
______________________________________ vs. ______________________________________
______________________________________ ______________________________________
Address Zip Code
Phone No. ____________________
STATEMENT OF CLAIM
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
DISTRICT OF COLUMBIA, ss: ______________________________________________________ being first duly sworn on oath says
the foregoing is a just and true statement of the amount owing by the defendant to plaintiff, exclusive of all set-offs and just grounds
of defense.
____________________________________________________ ____________________________________________________
Plaintiff /Agent (Sign and Print Name) Address City/State/Zip Code
Title:____________________________________________ ___________________________________________________
Email Phone No.
Subscribed and sworn to before me this __________ day of _______________________________________________, 20 ________
(month)
____________________________________________
(Notary Public or Deputy Clerk)
________________________________________________________________________________________________
Attorney for Plaintiff (Sign and Print Name) Bar No.
_________________________________________________________
Address City/State/Zip Code
Place Notary Seal Here
_________________________________________________________
Email Phone No.
NOTICE
(All parties must notify the Court of any address changes.)
To:
(1) ____________________________________________ (2) _____________________________________________________
Defendant Defendant
_______________________________________________ _____________________________________________________
Address City/State/Zip Code Address City/State/Zip Code
Home Business Home Business
You are hereby notified that ___________________________________________________ has made a
claim and is requesting judgment against you in the sum of _______________________________________
dollars ($___________), as shown by the foregoing statement. The Court will hold a hearing on this
claim on _________________________ in the Small Claims and Conciliation Branch, 510 4
th
Street, N.W.,
Court Building B, Courtroom 119.
See reverse side for complete instructions. ______________________________________________
Bring this Notice with you at all times. Clerk of the Court or Deputy Clerk
CV-471 / June 2018 / Small Claims Form 11 Superior Court of the District of Columbia