STATEMENT OF SERVICE (DELIVERY) –
SMALL CLAIMS
JD-CV-123 Rev. 4-19
P.B. § 24-10
Instructions
If filed on paper, fill out one (1) form for each defendant. Attach all documents showing how the Small
Claims Writ and Notice of Suit (form JD-CV-40) and related documents were served on (delivered to)
the defendant, and check the box below that applies. Keep all receipts showing how much you paid
to have the Small Claims Writ and Notice of Suit and related documents served on the defendant.
If filed electronically, follow the instructions above and ensure that you select the appropriate name of
the document you are filing.
For service on (delivery to) the defendant:
(Write name of defendant above)
The Small Claims Writ and Notice of Suit (form JD-CV-40) and related documents, if any, were served on (delivered to) the
defendant named above by:
(Check the box that applies)
1.)
priority mail with delivery confirmation; delivery confirmation is attached. I paid $
for this, or
2.)
certified mail, return receipt requested, or with electronic delivery confirmation; signed return receipt, or electronic
for this, or
3.)
a nationally recognized courier service providing delivery confirmation; tracking information showing delivery
for this, or
4.)
a proper officer in the manner in which a writ of summons is served in a civil action; officer's return of service
is attached. I paid $
filed with the court.
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
Date signedPrint name
Signed (Plaintiff or plaintiff's representative)
I paid $delivery confirmation, is attached.
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the
Americans with Disabilities Act (ADA). If you need a reasonable
accommodation in accordance with the ADA, contact a court
clerk or an ADA contact person listed at www.jud.ct.gov/ADA
COURT USE ONLY
SMRSOS
*SMRSOS*
