For Court Use Only
IN THE DISTRICT COURT OF LEAVENWORTH COUNTY, KANSAS
Small Claims Procedure, K.S.A. 61-2701 et seq.
Plaintiff’s Name
Phone Numbe
Address, City, State, Zip
vs. Case Number
Defendant’s Name
Phone Numbe
Address, City, State, Zip
INSTRUCTIONS TO PLAINTIFF:
1. State the claim you have against defendant(s) below. Be clear and concise. You must file original and copies for service.
2. Your total claim against defendant may not exceed $4,000.00, NOT including interest, costs, and any damages awarded under
3. KSA 60-2610. If you’re seeking recovery of personal property, the value of said property shall be based on your estimate of its
value
4. under unsworn declaration under penalty of perjury.
5. You must be present in person at the hearing in order to avoid default judgment against you on any claim defendant(s) may have
6. which arises out of the transaction or occurrence which is the subject of your claim.
7. You must make demand for judgment in one or both of spaces provided on this form.
8. Neither you nor the defendant(s) are permitted to appear with an attorney at the hearing, except as provided by KSA 61-2714.
9. You may not file more than twenty (20) Small Claims Petitions during any calendar year.
10. You must keep the court informed of any change in addresses and/or phone number.
11. After completing this Petition, you must sign it. Your signature is under unsworn declaration under penalty of perjury.
PETITION
PURSUANT TO CHAPTER 61 OF K.S.A.
Having read Instructions to Plaintiff, I hereby assert the following claim against above defendant(s):
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Based on the above stated claim, judgment is demanded against the defendant(s):
______ Payment of $_________, plus interest, costs and any damages awarded under K.S.A. 60-2610
______Recovery of described personal property_________________________________ valued at $_______________, plus costs.
I hereby declare under penalty of perjury under the laws of the State of Kansas that to the best of my knowledge and belief
the above claim asserted against the defendant(s) (including the estimated value of any property sought to be recovered)
is a just and trust statement, exclusive of any valid claim or defense which the defendant(s) may have.
____Request personal or residential service and not return receipt service. $
You may make return receipt service yourself.
Date executed_________________________________________ _____________________________________________________________
Plaintiff (Signature)
This communication is an attempt to collect a debt and any information obtained will be used for that purpose.
