Fill and Sign the Instructions for Completing Form a

Small Claims - $3,000 Limit Auto Revised 11/17/2014, CN 10148 p age 1 of 2 Instructions for Completing Form A (Small Claims Complaint – Motor Vehicle ) This complaint must be used only if your case involves a motor vehicle accident and you want to file a complaint in Small Claims Court. After you fill in the required information at the top of the form, in the middle section of the pag e, below the word COMPLAINT, complete the following information: 1.T ype or print the date the accident occurred. 2. Type or print the name of the defendant(s). a.After the word Owner , type or print the name of the owner of the vehicle in the space. b. After the wor d Operator, type or print the name of the person who was driving the car in the space. 3. Type or print the name of the place where the accident occurred. You can use the name of the street or the name of the streets at an intersection near the accident if y ou do not have an exact address. 4. In the space after the word Demand , enter the amount you are suing for in court. 5. Complete the information regarding interpreters or accommodation for a disability. 6. If the Complaint (Form A) or any of the copies of papers th at you attach to the complaint contain a Social Security number, driver’s license number, vehicle plate number, insurance policy number, active financial account number or active credit card number, you must redact (black out) this information so that it c annot be seen, unless any such personal identifier is required to be included by statute, rule, administrative directive or court order. If an active financial account is the subject of your case and cannot otherwise be identified, you may use the last four digits of the account to identify it. NOTE: Do not redact (black out) this information in the original papers that you are keeping since you may have to show them to the court at some point. 7. Date and sign the form. IMPORTANT NOTE: You cannot use this form for any matter other than for injuries to you or your property resulting from a motor vehicle accident . SMALL CLAIMS COMPLAINT (Motor Vehicle) NOTICE: This is a public document, which means the document as submitted will be available to the public upon request. Therefore, do not enter personal identifiers on it, such as Social Security number, driver’s license number, vehicle plate number, i nsurance policy number, active financial account number, or active credit card number. Plaintiff or Filing Attorney Information: Court Name Name of Court NJ Attorney ID Number Address Address Telephone Number Telephone Number From Pla intiff Superior Court of New Jersey Name Law Division, Special Civil Part Address Small Claims Section County Telephone Number Docket No: To Defendant (to be provided by the court) Name Civil Action Complaint Motor Vehicle Address Telephone Number COMPLAINT Plaintiff says the negligence of the defendant operator and/or defendant owner caused a motor vehicle accident resulting in property damage to plaintiff's vehicl e, in the following accident: 1. Date of Accident: . 3. Place of Accident: 2. Name of Defendant(s) a) Street: . a) Owner : . b) Municipality : . b) Operator : . c) County: . Demand: $ . IMPORTANT: Plaintiffs and defendants must bring all witnesses, photos, and documents, and other evidence to the hearing. Subpoena forms are available at the Clerk’s office to require the attendance of witnesses. At the trial Plaintiff will require: An interpreter Yes No Indicate Language An accommodation for disability Yes No Indicate Disability I certify that the matter in controversy is not the subject of any other court action or arbitration proceeding, now pending or contemplated, and that no other parties should be joined in this action. I certify that confiden tial personal identifiers have been redacted from documents now submitted to the court, and will be redacted from all documents submitted in the future in accordance with Rule 1:38 -7(b). Date Plaintiff’s Signature Plaintiff’s Name Typed, Stamp ed or Printed p age 2 of 2 Revised 11/17/2014, CN 10148 Revised 09/04/2012, CN 10533 (Appendix XI -D)