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IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE THIRD JUDICIAL DISTRICT Small Claims Division - P.O. Box 12869, Salem, OR 97309
______________________________________________ Plaintiff ______________________________________________ Address ______________________________________________ City State Zip ______________________________________________ Telephone County vs. ) ) ) ) ) ) ) ) )

CLAIM AND NOTICE OF CLAIM Case No. _______________________

Name, Title (if applicable) and Address for Service on Defendant(s): ______________________________________________ Defendant #1 ______________________________________________ A.K.A./DBA(Please circle one) ______________________________________________ Address ______________________________________________ City State Zip County ______________________________________________ Telephone ____________________________________________________ Defendant #2 ____________________________________________________ A.K.A./DBA(Please circle one) ____________________________________________________ Address ____________________________________________________ City State Zip County ____________________________________________________ Telephone

I, Plaintiff, claim that on or about _______________, 20___, the above-named Defendant(s) owed me the sum of $__________, and this sum is still owing, for (reason)_____________________ ___________________________________________________ ________________________________________________________________________________________________________. I have incurred fees of $____________ and service expenses of $______________. STATE OF OREGON, ) ) COUNTY OF MARION ) Claim Amount: Filing Fee: Service Fee: Total Due: ___________________ ___________________ ___________________ ___________________

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I, the above-named plaintiff, having been duly sworn, state that I have read the above claim and that it is true as I verily believe, and that I have made a bona fide effort to collect the claim from the defendant before filing the claim with the clerk. DATED: _____________________________________ _______________________________________ Plaintiff SUBSCRIBED AND SWORN to before me this _____ day of _______________, 20_____. TRIAL COURT ADMINISTRATOR/NOTARY PUBLIC FOR OREGON (SEAL) By: ____________________________________ My Commission expires: ___________________ NOTICE TO DEFENDANT: I certify that the foregoing is a true copy of a claim filed against you. TRIAL COURT ADMINISTRATOR (SEAL) By: ____________________________________ NOTICE TO DEFENDANT - READ REVERSE SIDE FC (1/23/09)

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