Free CCM N008 1-28-04 - Illinois

Small Claims Complaint-Verified

(Claims under $10,000)

(1/03/06) CCM 0750

IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS MUNICIPAL DEPARTMENT, __________ DISTRICT

_______________________________________________
Plaintiff(s)

v.

_______________________________________________
Defendant(s)

}

No. _____________________________________

Amount Claimed: $ _________________________
Return Date: ______________________________

SMALL CLAIMS COMPLAINT-VERIFIED
(IL Sup. Ct. Rules 281-288)

The Plaintiff(s) claim(s) as follows: 1. Defendant(s) Name(s) and Address(es): ___________________________________________________________

_____________________________________________________________________________________________
2. Defendant(s) owe(s) me $ ___________________ for the reasons set forth below.

3. Defendant(s) owe(s) me this amount for the following reasons (State nature of your claim including dates and other relevant information. Use additional sheet(s) if necessary):

I, __________________________________________, certify that I am the Plaintiff in the above entitled action.
(Plaintiff's Name)

Under penalties as provided by law pursuant to 735 ILCS 5/1-109 the undersigned certifies that the statements set forth herein are true and correct. Atty. No.: ______________ Atty. (or Pro Se Plaintiff): Name: __________________________________________ Address: ________________________________________ City/State/Zip: ___________________________________ Telephone: ______________________________________ Dated:___________________________, ________ Pro Se 99500

________________________________________ Signature

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS