STATEMENT OF SMALL CLAIM
AND NOTICE
Trial Court of Massachusetts
Small Claims Session
COURT DIVISION WHERE THE PLAINTIFF IS FILING THIS CLAIM (Select Only One Court):
PLAINTIFF INFORMATION: The person filing the claim is the plaintiff.
Pltf. Name:
Address:
City/State/Zip:
Phone No.:
PLAINTIFF'S ATTORNEY (if any)
Atty. Name:
Address:
City/State/Zip:
Phone No.: BBO NO:
Def. #1 Name:
Address:
City/State/Zip:
Phone No.:
Def. #2 Name:
Address:
City/State/Zip:
Phone No.:
MEDIATION: Mediation of this claim may be available if both parties agree to discuss the matter with a mediator, who will assist the parties
in trying to resolve the dispute on mutually agreed to terms. The plaintiff must notify the court if he or she desires mediation; the defendant
may consent to mediation on the trial date. The plaintiff is willing to attempt to settle this claim through mediation: YES NO
The Plaintiff claims that the Defendant(s) OWE plus court costs for the following reasons
:
MILITARY AFFIDAVIT: The plaintiff states under the pains and penalties of perjury that the:
above defendant(s) is (are) not serving in the military and at present live(s) or works at the above address.
above defendant(s) is (are) serving in the military. I am unsure if the above defendant(s) is (are) in the military.
www.mass.gov/courts
Efile: 6/5/2018
BMC:
District:
Housing:
NOTICE TO PLAINTIFF: You may file your small claim only in the court for the area where either the plaintiff or the defendant lives or has a place of
business or employment. A small claim against a landlord arising from the rental of an apartment may also be brought where the apartment is located. You
may find it easier to enforce a decision in your favor if you bring your small claim where the defendant lives or works, but you are not required to do so.
SIGNATURE OF PLAINTIFF: X
DATE:
PLAINTIFF'S CLAIM: Fill in below the amount you are suing for and briefly explain your claim. State your claim clearly so the defendant
can understand why he or she is being sued. Give the date of the event that is the basis of your claim. Fill in as "costs" the amount of the
filing fee.
DEFENDANT(S) INFORMATION:
The person or corporation being sued is the defendant. If you are suing a company which is not a corporation, you
should name the owner(s) doing business as the named company as the defendant; the names of the owner(s) can be obtained from the City or Town Clerk
where the company's offices are located. If you are suing a company which is a corporation, you must have the exact legal name. You can find this
information from the Corporate Records Division of the Secretary of State's Office, One Ashburton Place, Room 1712, Boston, MA 02108.
SIGNATURE OF PLAINTIFF: X DATE:
INSTRUCTIONS TO PLAINTIFF: "By E-Filing this form, which includes the military affidavit, you certify that the above information is true and
accurate. By completing this form, together with a payment of the filing fee, the form will be sent to the court electronically. If you do not know
where to file your Small Claims case visit: www.mass.gov/courthouse-locator. If a claim arises out of plaintiff's trade or commerce, or for
assigned debt, you may be required to complete and file a "Verification of Defendant's Address" form."
DOCKET NO. (For Court Use Only)
Click HERE for additional Small Claims information
