Form KS41

Small Claims Procedure

~ PETITION .r DISTRICT COURT OF Ci1il4foccA

COUNT~KANSAS

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aintiff name and address

Defendant name and address

Plaintiff: Read instructions on bottom of this form. Set forth a short and plain statement of your claim below.

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Based on the claim stated above, judgment is demanded against defendant as follows:
ii1Payment of $ ~33 3 ,plus interest, costs and any damages awarded under K.S.A. §60-26LO.
o Recovery of the following described personal property, plus costs--estimated value of property $, _

The plaintiff hereby declares under penalty of perjury under the laws of the State of Kansas that, to the best of plaintiff's
knowledge and belief, the above claim asserted against the defendant (including the estimate of value of any property
sought to be recovered) is a just, true, and correct statement, exclusive of any valid claim or defense which defendant may
have.
o Check this box if the plaintiff is an attorney or a corporation or e itYjthat will appear by an attorney or former
attorney or person qualified to be an attorney as defined by law. ...,...--~--

Executed on / (J 1151 1:(}faX ----1~"""q,..£""'--:---"'~=;;:;::;,.,.....,.,crr------

I I" j T Signature of Plaintiff .
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o Indicate this box to request personal or residence service of the summons and not return receipt service.
receipt service yourself. Follow strict terms of the rerum forms if you make the service yourself.
You may make return

This communication is an attempt to collect a debt and any information obtained will be used for that purpose.

INSTRUCTIONS TO PLAINTIFF:
1. State the claim you have against the defendant in the space provided on the petition form. Be clear and concise.
2. Your total claim against defendant may not exceed $4,000, not including interest. costs and any damages awarded
under K.S.A. §60-26JO. If you are seeking the recovery of personal property, the value of that property shall be based
on your estimate of its value under unsworn declaration under penalty of perjury.
3. You must be present in person at the hearing in order to avoid default judgment against you on any claim defendant
may have which arises out of the transaction or occurrence which is the subject of your claim against the defendant.
4. You must make demand for judgment in one or both of the spaces provided on the petition form.
5. Except as provided by law, neither you nor the defendant are permittee! to appear with an artorney at the hearing
unless the other party is an attorney or is a corporation or entity that uses an attorney in a representative capacity. In su~h
case you are entitled to one continuance to obtain an attorney.
6. You may not file more than twenty small claims under the small claims procedure act in this court during any
calendar year.
7. After completing the petition form, you must sign it. Your signature is under unsworn declaration under penalty of
perjury. .

© Copyright 2018. NDF Co .. P.O. Box 725. Newton, Kansas 67114. Reorder Ph. 316-·283-3628. Fw ....3\b-283-3bJ5
 Date: 10/15/2019 Crawford County District Court (Pittsburg) NO. 0387744
Time: 03:45 PM Receipt Page 1 of 1

Received of: Day, Noah Ian (plaintiff) $

----67.50

Sixty-Seven and 50/100 Dollars

Case: 2019-SC-000054-P Plaintiff: Noah Ian Day vs. Brent Narges Amount
Small Claims Docket Fee ($500.01 - $4,000) 67.50

Total: 67.50

Payment Method: Cash

Amount Tendered: 67.50

By:
Clerk 1 Deputy Clerk