Fill and Sign the Employment Department Oregon Claim Online Form

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF ____________ SMALL CLAIMS DEPARTMENT PLEASE PRINT LEGIBLY __________________________________________) ) __________________________________________) Plaintiff ) __________________________________________) Address (include zip code) ) __________________________________________) No. _______________________ Telephone Number ) ) ) CLAIM AND NOTICE OF ) CLAIM vs ) ) ) __________________________________________) Defendant ) __________________________________________) Address (include zip code) ) __________________________________________) Telephone ) I, Plaintiff, claim that on or about _______________, 20____, the above-named Defendant of _______________ County, Oregon, owed me the sum of $__________, and this sum is still owing, for ___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 .STATE OF OREGON, ) )ss COUNTY OF ___________ ) 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. _________________________________ Plaintiff Subscribed and sworn to before me this _____ day of _______________, 20___. TRIAL COURT ADMINISTRATOR (SEAL) By: ____________________________________ Total filing fees and service expenses paid $____________. NOTICE TO DEFENDANT: I certify that the foregoing is a true copy of a claim filed against you. (SEAL) By: ____________________________________