(FOR OFFICE USE ONLY) INSTRUCTIONS: CIVIL COURT OF THE ...

1 (FOR OFFICE USE ONLY) CIVIL COURT OF THE CITY OF NEW YORKSMALL CLAIMS PARTSTATEMENT OF CLAIMINSTRUCTIONS:Place only ONE letter or number in each spaceand leave a blank space between claimant 'S INFORMATION(Your)LAST NAMEMIDDLE INITIALFIRST NAMEBOROUGH, CITY,ZIPSTATETOWN OR INFO[Doing Business As] [In Care Of]PHONE NO.[Attention To] Circle OneCERT'D #II. DEFENDANT'S INFORMATION*(Their)LAST NAMECOA CODE(or Full Business Name)FIRST NAMEMIDDLE INITIALCLAIM AMT.$BOROUGH CITY,ZIPSTATEFEETOWN OR FEEOTHER INFOCLAIMANT V. DEFENDANTPHONE V. THIRD PARTYNO FEEIII. CLAIMCLAIMANT V. ADD'L DEFENDANTDate of Occurrence or Transaction:Amount Claimed: $(Maximum $5, 000)WAGE CLAIM TO $300 Place of occurrence, if Auto AccidentLANGUAGEPRIMARY REASON FOR CLAIM (Check One):automobileDamage caused to: other personal propertyreal propertypersonDATE DATA ENTERED proper servicesproper merchandiseproper repairsFailure to provide:goods paid forFailure to return:propertysecuritydepositmoney loanedinsurance claimsalaryfor services renderedFailure to pay:DATE NOTICES MAILED commissionsrentfor goods sold and deliveredBreach TYPE:use of propertyLoss of:luggagepropertytime from workMULTI DFTCTR/CLMR eturned:check (bounced)check (stopped) other .

2 (Be brief)3 PARTYCRS/CMPLTFIRST DATEIDENTIFYING NUMBER(S) - (Receipt #, Claim #, Account #, Policy #, Ticket #, License #, Plate #'(s))Today's DateSignature of claimant or AgentDAY COURTSTATUTORYOTHER* 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 theOffice of the County Clerk in the county in which the business is located or check on the following website: 'S ADDRESS: YOU must indicate the proper street address of the Defendant. A Post OFFICE Box is not : If the Claim is a result of an automobile accident, the Claim must be OWNER against (Revised 7/05)ADDRESS(NO BOX)ADDRESS(NO BOX)[Doing Business As] [In Care Of][Attention To] Circle OnePOSTAGE ONLYFREE CIVIL COURT FORMNo fee may be charged to fill in this can be found