SUPERIOR COURT OF THE DISTRICT OF COLUMBIA F LED
`
`Civil Division - Small Claims and Conciliation Branch
`510 4th Street, NW, Room 120, Washington, D.C. 20001
`(202) 879-1120 | www.dccourts.gov
`
`OCT 2 2 2024
`Glerk
`Superior Court
`of the District of Columbia
`Small Claims Branch
`
`Case No
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`OO
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`Plaiftiff(s)
`Address
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`Phone Nu
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`vs.
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`Address
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`City,
`Phone Number
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`DOC?
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`Email Address
`
`Email Address
`STATEMENT OF CLAIM
`
`Request for Relief:
`
`7,
`
`DISTRICT OF
`COLUMBIA, ss:
`the foregoing is
`Just and
`grounds of defense.
`Plaintiff.gent6ign and Print Name
`Code Title:
`
`taterf]ent of the
`
`Subscribed and sworn to before me this 22
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`day of.
`
`being first duly sworm on oath says
`owing by/thé defendant{ to plaintiff, exclusive of all setoffs and just
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`Email
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`(month
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`City/State/Zip
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`22-297
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`No
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`See the Instructions to Defendants attached to this form, for more information
`
`Small Claims Form 11
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`Atto
`
`Address
`Code
`
`Email
`
`CVATI/Sulv 2023
`
`

`

`Instructions to Defendants
`
`Important:
`
`You must participate in your hearing on the date.and time stated on the Notice to avoid the entry of a
`judgment by default. If you do not come to court for your hearing, a judgment by default may be entered
`against.you for the amount of money demanded in the Statement of Claim. If that happens, the plaintiff
`could take money from your paycheck or your bank account, or take and sell your personal.property, to
`pay the claim.
`
`:
`
`If you cannot participate in your hearing, call the Small Claims Clerk's Office at (202) 879-1120 as soon
`as you can for more information. You must go to the hearing unless the hearing is continued or cancelled.
`To find outif your hearing isstill scheduled call the Small Claims Clerk's Office. Even if you want to
`admit the claim, and just need more time to pay, you must still come to court to explain your situation.
`
`Before any case goes to trial in the Small Claims and Conciliation Branch, a trained mediator will meet with the
`parties to see if they can agree to a settlement. If the parties cannot reach a settlement with the mediator, then
`the case can be scheduled for a trial on another day.
`
`If the plaintiff in your case has a lawyer, that lawyer's name and contact information are on the Statement.of
`Claim. You may contact the plaintiff's lawyer about this case. You do not have to have a lawyer, but you may
`choose to get a lawyer or look for legal advice about this matter.
`
`If you want a lawyer, but cannot afford to pay one, there are many organizations that may be able to help you,
`including:
`
`Legal Aid Society of the District of Columbia: (202) 628-1161
`Legal Counsel for the Elderly (if age 60+): (202) 434-2120
`Tzedek DC: (202)274-7386
`Neighborhood Legal Services Program: (202) 832-6577
`DC Law Students in Court: (202) 638-4798
`If you have witnesses, books, receipts, or other documents that relate to this case, you should bring them with
`you to court. If you want to have witnesses summoned to come to court, contact the Small Claims Clerk's
`Office for more information.
`
`When you contact the Small Claims Clerk's Office about your case, remember to include your case number,
`contact information, and court date. Please know that court employees are not allowed to give you legal advice.
`
`Usted puede obtener copias en espaiiol de este formulario en el Tribunal Superior del Distrito de
`Columbia, Edificio B, 510 4th Street, NW, Cuarto 120, Washington, D.C. 20001, o en: www.dccourts.gov.
`
`You can get a copy of this form in Spanish at the Superior Court of the District of Columbia, Building B,
`510 4th Street NW, Room 120, Washington, D.C. 20001, or at: www.dccourts.gov.
`
`

`

`of co
`
`Plaintiff(s)
`
`Defendant(s
`
`zh
`
`y
`
`v.
`
`A
`
`ame (v ease print or type)
`t
`
`Firm me (ifapplicabley
`
`Telephone No.
`
`(The information collected on thisform is
`used solelyfor court administration and
`statistical purposes.)
`
`Relationship to Lawsuit:
`Attorney for Plaintiff
`Other:
`
`Self (Pro Se / No Attorney)
`
`Bar. No
`
`Se
`ce Method
`WYCertified Mail by Clerk (How many?
`With Restricted Delivery (check ifapplicable)
`[] Registered Mail by Clerk (How many?
`With Restricted Delivery (check ifapplicable)
`Cial Process Server (You must file an
`Application for Approval of Special Process Server)
`Ifyes, which language(s)?
`
`(t-s2,500.01 -$10,000
`
`SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
`Civil Division - Small Claims and Conciliation Branch
`510 4" Street, N.W., Court Building B, Room 120, Washington, D.C. 20001
`Telephone Number: (202) 879-1120 Website: www.dccourts.gov
`
`Do you need an interpreter? [] Yes
`$1-$500
`Amount in Controversy:
`$500.01 -$2,500
`Pending or re-filed case(s) related to the action being filed:
`Case No.:
`
`Case No.:
`
`NATURE OF SUIT: -(Check ONE box.only that most.accurately describes-your primary case)
`A.. CONTRACTS - a.claim based on an agreement between parties made either orally or in writing
`Breach of Contract
`Breach of Warranty
`Personal Property
`{] Rent Due
`Loan
`CL] Negotiable Instrument
`[]. Security Deposit
`Services Rendered
`Unpaid Wages
`[] Home Improvement Contract
`Debt Suit
`IB. PROPERTY TORTS - aa claim for an injury or wrong committed on the property of another
`[] Shop Lifting
`[] Automobile
`Conversion
`Destruction of Property
`Property Damage
`C. PERSONAL TORTS a claim for an injury or wrong committed on the person of another
`[] Personal Injury
`Libel and Slander
`Assault and Battery
`[] Negligence
`Automobile
`Fraudulent Misrepresentation
`D. (] UNIFORM ARBITRATION ACT - an action based
`E. L] SUBROGATION - a claim filed by one
`person in the place of another
`on an arbitration agreement
`G. O COLLECTION - a claim filed by a
`FOREIGN JUDGMENT (DOMESTIC) -
`seller / lender to collect a consumer debt
`judgment, decree or order filed from another jurisdiction
`H. CJ FOREIGN JUDGMENT (INTERNATIONAL) - judgment, decree or order filed from another country
`EDICAL MALPRACTICE - a claim against a healthcare provider for professiopat misconduct
`Yes
`No
`Have ou iven notice of intention to file your lawsuit 90 days prior to filing?
`CV-3046/Rev. Sept. 2018
`
`F.
`
`e6
`
`