Free Statement of Claim - New York

INSTRUCTIONS: Place only ONE letter or number in each space and leave a blank space between words.

CIVIL COURT OF THE CITY OF NEW YORK SMALL CLAIMS PART STATEMENT OF CLAIM

(FOR OFFICE USE ONLY)

(Your) LAST NAME FIRST NAME ADDRESS (NO P.O. BOX) BOROUGH, CITY, TOWN OR VILL. OTHER INFO
[Doing Business As] [In Care Of] [Attention To] Circle One

I. CLAIMANT'S INFORMATION

MIDDLE INITIAL

STATE

ZIP

PHONE NO. II. DEFENDANT'S INFORMATION*

CERT'D #

(Their) LAST NAME
(or Full Business Name)

COA CODE

FIRST NAME ADDRESS (NO P.O. BOX) BOROUGH CITY, TOWN OR VILL. OTHER INFO
[Doing Business As] [In Care Of] [Attention To] Circle One

MIDDLE INITIAL
CLAIM AMT.

$ STATE N Y ZIP
FEE STANDARD FEE CLAIMANT V. DEFENDANT NO FEE DEFENDANT V. THIRD PARTY CLAIMANT V. ADD'L DEFENDANT POSTAGE ONLY WAGE CLAIM TO $300

PHONE NO. III. CLAIM

Amount Claimed: $

(Maximum $5, 000)

Date of Occurrence or Transaction:

Place of occurrence, if Auto Accident PRIMARY REASON FOR CLAIM (Check One): Damage caused to: automobile other personal property proper services proper repairs Failure to provide: Failure to return: property security salary Failure to pay: for services rendered commissions rent Breach of. contract lease Loss of: luggage property Returned: check (bounced) check (stopped) Other: (Be brief)

LANGUAGE real property proper merchandise deposit insurance claim for goods sold and delivered warranty time from work person goods paid for money loaned DATE DATA ENTERED DATE NOTICES MAILED agreement use of property CASE TYPE: MULTI DFT 3 PARTY FIRST DATE DAY COURT CTR/CLM CRS/CMPLT

IDENTIFYING NUMBER(S) - (Receipt #, Claim #, Account #, Policy #, Ticket #, License #, Plate #'(s)) Today's Date Signature of Claimant or Agent

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. FREE CIVIL COURT FORM DEFENDANT'S ADDRESS: YOU must indicate the proper street address of the Defendant. A Post Office Box is not acceptable. No fee may be charged to fill in this form.
CIV-SC-50 (Revised 7/05) NOTE: If the Claim is a result of an automobile accident, the Claim must be OWNER against OWNER. Form can be found at http://www.nycourts.gov/courts/nyc/smallclaims/forms.shtml.