Fill and Sign the Synthesis of Kentuckys Traveler Information Systems

Assigned Court Date: _________ __________________ Plaintiff: [ ] Company [ ] Individual (for individual, enter first, middle and last names) Name __________________________________________________________________________________ Address ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ _________ ________________________________________________________________________\ _ Plaintiff’s Attorney (if any): [ ] Firm [ ] Individual Name __________________________________________________________________________________ Address ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________ __________________________________________________________________ Defendant: [ ] Company [ ] Individual (for individual, enter first, middle and last names) Name __________________________________________________________________________________ Address ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ____________ ______________________________________________________________________ NOTICE TO EA CH DEFENDANT - READ CAREFULLY You are being sued in Small Claims Court by the Plaintiff shown above. The judge has not made a decision in this case. You are to appear in court on the date shown on the attached summons to tell your side of the dispute. If you fail to appear in court on the date shown on the attached summons, a court judgment may be taken against you for the money or property demanded in the Claim on page 2 of this document. This could lead to garnishment of your paycheck and/or sale of your home or other belongings (unless protected by law) to satisfy the judgment. If you have questions or need assistance, consult the Small Claims information pamphlet (P-6) or call an attorney. Case No. ____________________ Court _______________________ County ____ __________________ AOC- 175 Doc. Code: COM Rev. 5-11 Page 1 of 2 Commo nwealth of Kentucky Court of Justice www.courts.ky.gov KRS 24A.260 SMALL CLAIMS COMPLAINT lex et justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE District Small Claims WARNING REGARDING JURY TRIAL (KRS 24A.320; 29A.270) There are no jury trials in Small Claims Court. If the amount in controversy exceeds $250, you may have a jury trial by going into District Civil Court. However, the simplified and informal procedures used in Small Claims Court do not apply in District Civil Court. If you request a jury, you will be required to pay an additional fee. To the Plai ntiff: If you want a jury trial, file your claim in District Civil Court instead of Small Claims Court To The D efendant: If you want a jury trial, you must notify the court clerk in writing at least seven (7) days before the court date listed on the attached summons to have the case transferred from Small Claims Court to District Civil Court. Clerk ___________________________________________ Address ___________________________________________ ___________________________________________ ___________________________________________ Phone No. ______ _____________________________________ AOC 175 Doc. Code: COMRev. 5-11 Page 2 of 2 CLAIM 1. Plaintiff claims Defendant: ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ________________________________________________________________________\ _______________________ ____________________________ ___________________________________________________________________ NO TE TO PLAINTIFF: Only the Complaint will be served on the Defendant. Attachments WILL NOT be served . 2. Plain tiff claims the sum of $ _______________________ from the defendant for damages incurred as a result of the above complaint. (The jurisdictional authority of Small Claims Court is $2,500.00, exclusive of interest and costs. KRS 24A.230). 3. Plaint iff also claims the following court costs: _____________________________________________________. Court costs will be added to any judgment rendered in favor of plaintif f. Date: ___ ________________________, 2______. _______________________________________________ Plaintiff’s or Attorney’s Signature Plaintiff’s Name ____________________________________________ SMALL CLAIMS AFFIDAVIT KRS 24A.250(1) reads as follows: No party shall file more than twenty-five (25) claims in any one (1) calendar year in the Small Claims Division of any District Court in the Commonwealth. Any business engaged in trade or commerce shall be entitled to the maximum number of claims allowed under this section of each established location in the district that has been engaged in trade or commerce for at least six (6) months. KRS 24A.250(4) exempts claims brought by city, county or urban-county governments from the limit on the number of claims that may be filed in a calendar year. I swear (or affirm) I have n ot brought more than the maximum number of claims allowed by KRS 24A.250\ . Date: ____________________________, 2_______. ___________________________________________ Affiant's Signature Subscribed and sworn to before me by ________________________________________________ this ____________ day of _____________________________, 2_______. My Commission expires: ____________________, 2_______. Signature: _ _____________________________________________ Title: _______ _______________________________________