This Small Claims Court Complaint Form (“Form”) is submitted to the [Court Name], [County/State], by the undersigned Plaintiff.
Court Name: [Court Name]
Court Address: [Street, City, State, ZIP]
Case Number (assigned by court): [Leave blank for clerk]
Full Legal Name: [Plaintiff Name]
Address: [Street, City, State, ZIP]
Phone: [Number]
Email: [Address]
Full Legal Name: [Defendant Name]
Address: [Street, City, State, ZIP]
Phone: [Number]
Email: [Address]
Amount of Claim: $[Amount]
Reason for Claim: [Brief description, e.g., “Unpaid loan of $2,000 dated [Date]”]
Date Claim Arose: [Date]
Location of Event/Transaction: [City/County]
5. Statement of Claim
The Plaintiff states the following facts in support of this claim:
[Provide concise but detailed statement of events leading to the dispute. Example: “On [Date], Defendant borrowed $2,000 from Plaintiff under an agreement to repay within 30 days. Defendant has failed to repay despite multiple requests.”]
6. Relief Requested
Plaintiff requests judgment against the Defendant for the claim amount stated above, plus allowable court costs and interest, as permitted by law.
7. Certification
I, the Plaintiff, certify that the information in this complaint is true and correct to the best of my knowledge, and that the amount claimed does not exceed the jurisdictional limit for small claims in this court.
Date: ________________________
Plaintiff Signature: ________________________
8. Clerk Use Only
Filing Fee Paid: $__________
Date Filed: ____________________
Clerk’s Initials: _____________