(FOR OFFICE USE ONLY)
CIVIL COURT OF THE CITY OF NEW YORK
SMALL CLAIMS PART
STATEMENT OF CLAIM
INSTRUCTIONS:
Place only ONE letter or number in each space
and leave a blank space between words.
I. CLAIMANT'S INFORMATION
(Your)
LAST NAME
MIDDLE INITIAL
FIRST NAME
BOROUGH, CITY,
ZIP
STATE
TOWN OR VILL.
OTHER INFO
[Doing Business As] [In Care Of]
PHONE NO.
[Attention To] Circle One
CERT'D #
II. DEFENDANT'S INFORMATION*
(Their)
LAST NAME
COA CODE
(or Full Business Name)
FIRST NAME
MIDDLE INITIAL
CLAIM AMT.
$
BOROUGH CITY,
ZIP
STATE
FEE
TOWN OR VILL.
STANDARD FEE
OTHER INFO
CLAIMANT V. DEFENDANT
PHONE NO.
DEFENDANT V. THIRD PARTY
NO FEE
III. CLAIM
CLAIMANT V. ADD'L DEFENDANT
WAGE CLAIM TO $300
Place of occurrence, if Auto Accident
LANGUAGE
PRIMARY REASON FOR CLAIM (Check One):
automobile
Damage caused to:
other personal property
real property
person
DATE DATA ENTERED
proper services proper merchandise
proper repairs
Failure to provide:
goods paid for
Failure to return:
property
security
deposit money loaned
insurance claim
salary
for services rendered
Failure to pay:
DATE NOTICES MAILED
commissions
rent
for goods sold and delivered
Breach of.
contract
lease
warranty
agreement
CASE TYPE:
use of property
Loss of:
luggage
property
time from work
MULTI DFT
CTR/CLM
Returned:
check (bounced) check (stopped)
3 PARTY
CRS/CMPLT
FIRST DATE
Today's Date
Signature of Claimant or Agent
DAY COURT
STATUTORY
OTHER
* DEFENDANT'S NAME: The legal name will be required in order to obtain an enforceable judgment. If the Defendant is a business, its full and correct business name should he obtained from the
Office of the County Clerk in the county in which the business is located or check on the following website: www.dos.state.ny.us.
DEFENDANT'S ADDRESS: YOU must indicate the proper street address of the Defendant. A Post Office Box is not acceptable.
NOTE: If the Claim is a result of an automobile accident, the Claim must be OWNER against OWNER.
ADDRESS
(NO P.O. BOX)
ADDRESS
(NO P.O. BOX)
[Doing Business As] [In Care Of]
[Attention To] Circle One
POSTAGE ONLY
FREE CIVIL COURT FORM
No fee may be charged to fill in this form.
Form can be found at
http://www.nycourts.gov/courts/nyc/smallclaims/forms.shtml.
N Y
CIV-SC-50 (Revised
01
/28/21)
Date of Occurrence or Transaction:
(Maximum $10,000.00)
Amount Claimed: $
IDENTIFYING NUMBER(S) - (Receipt #, Claim #, Account #, Policy #, Ticket #, License #, Plate #'(s))
Other: (Be brief)
EMAIL
EMAIL
click to sign
signature
click to edit
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