Small Claims Department Form printable pdf download

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN

SMALL CLAIMS DEPARTMENT

Name

______________________________________________

CASE NO: ______________________________

Plaintiff(s)

SMALL CLAIM AND NOTICE OF CLAIM

Address ______________________________________________

At hearing, I will need an interpreter in the _________________ language.

______________________________________________

At hearing, I will need American’s with Disabilities Act accommodations.

Phone (_____) ________________

_______________

Inmate ID #

(If applicable)

vs.

Name

______________________________________________

Defendant(s)

If defendant is a business, serve: ________________________________________ (__Officer

__Reg. Agent

__Owner)

Address ______________________________________________

______________________________________________



Phone (_______) _____________

Defendant is a public body

I, Plaintiff, claim that on or about _________________________, the above named Defendant of _______________ County,

Oregon, owed me the sum of $___________________ and this sum is still owing for: ______________________________

___________________________________________________________________________________________________

CLAIMED AMOUNT $___________________

SMALL CLAIMS FEE: $___________________

COSTS & FEES PAID OR TO BE PAID:

SERVICE FEE:

$___________________

FORM FEE:

$___________________

TOTAL OWED:

$___________________

DECLARATION OF BONA FIDE EFFORT

I, Plaintiff, state I have made a Bona Fide effort to collect this claim from defendant before filing this claim with the Court. I,

Plaintiff, declare the above statements are true to the best of my knowledge and belief, and I understand they are made for use in

Court and I am subject to penalty for perjury.

Dated: ________________________

Signed: ______________________________________________________

____________________________________________________________

Print Plaintiff’s Name

___________________________________________

**Email Address

**Email Notification Consent: By providing my email address I consent to receive notifications from the court by email instead of or in addition

to other methods. I understand that if my email changes or if I choose to withdraw consent, I must notify the court in writing.

ATTENTION DEFENDANT: YOU MUST READ NOTICE ON THE REVERSE SIDE.

Rev 01/16

Small Claims Department Form

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