Small Claims Complaint Form -
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1NASSAU DISTRICT COURT - SMALL CLAIMS COMPLAINT FORM
STATE DETAILS OF YOUR CLAIM: _____________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Date of Occurrence or Transaction: ______/_______/_______
Total Amount of Claim ($5,000 Maximum) ______________
CLAIM ANT’S Information (No P.O. Boxes)
First Name ____________________ M iddle __________________ Last ______________________________________
DBA_____________________________________________________________________________________________
Address:_________________________________________
City________________________ State _________ Zip______________
DEFENDANT’S Information (M ust Have Nassau County Address - No P.O. Boxes)
First Name ______________________ M iddle ________________ Last ______________________________________
or Legal Business Name ____________________________________________________________________________
Address:_________________________________________
City________________________________ State NY Zip______________
Check One
Additional Claimant Information (No P.O. Boxes) or
if additional party
Additional Defendant Information (M ust Have Nassau County Address - No P.O. Boxes)
First Name ______________________ M iddle ________________ Last ______________________________________
or Legal Business Name ____________________________________________________________________________
Address:_________________________________________
City________________________________ State _________ Zip______________
The undersigned acknowledges that they shall be deem ed to have waived all rights to appeal except on the sole ground
that substantial justice has not been done.
The undersigned has also been advised that supporting witnesses, account books, receipts and other docum ents required
to establish the claim m ust be produced at the hearing.
________________________________
___________
Signature of Claimant
Date
COURT USE ONLY BELOW THIS LINE
Index Number __________________________
Hearing Date________________
Breach of Contract or W arranty
Failure to pay for wages
Personal Injuries
Breach of Lease or Rental
Failure to provide goods ordered
Professional Fees
Agreem ent
Failure to provide proper services
Property Dam age
Car Rental Expenses
Failure to return property
Refund on Defective Merchandise
Consum er Credit
Goods Sold and Delivered
Refund on Defendant's Defective
W ork, Labor and/or Services
Dam ages caused to autom obile
Late Fees
Rent Due
Dishonored Check
Loss of Personal Property
Return of Deposit
Failure to Pay for Medical Services
Loss of Profit
Provided
Return of Security
Loss of tim e for work
Failure to issue a refund
Unpaid W ages
Loss of use of property
Failure to pay for com m issions
W ork, Labor and Services
Monies Due
Failure to pay for insurance claim
Paym ent of Loan
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