In the Municipal Court of Bellefontaine, Ohio

IN THE MUNICIPAL COURT OF BELLEFONTAINE, OHIO

SMALL CLAIMS DIVISION

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Plaintiff(s) Case No. ____CVI______

-vs-

______SMALL CLAIMS PETITION

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Defendant(s)

Now comes the Plaintiff(s) and says that he has a claim against Defendant(s) as follows:

Statement of Claim

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Amount Claimed $______

Demand for Relief

Wherefore, Plaintiff demands judgment against Defendant(s) as aforesaid, plus filing fees and costs.

Signature of Plaintiff or Agent: ______

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State of Ohio, Logan County, SS:

Before me, a person duly authorized to administer an oath, personally appeared the above-named affiant who, being

first duly sworn, stated that the foregoing Statement of Claim was true, that the amount claimed therein was justly due, and that defendant(s) were not in the military service, IN TESTIMONY WHEREOF, I hereunto set my hand and affix my official seal this ______day of ______, 201___.

Signature of Notary Public,

Deputy Clerk/Clerk of Courts: ______

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Summons and Notice to Defendant(s)

You will hereby take Notice that the above-named plaintiff(s) has filed a claim against you in the Small Claims

Division of the Bellefontaine Municipal Court, as set forth above. IF YOU DO NOT APPEAR at the trial,

JUDGMENT MAY BE ENTERED AGAINST YOU by default, and your earnings may be subjected to garnishment

or your property may be attached to satisfy said judgment. If your defense is supported by witnesses, account books,

receipts or other documents, you must produce them at the trial. Subpoenas for witnesses, if requested by a party, will

be issued by the Clerk. If you admit the claim but desire time to pay, you may make such a request at the trial.

If you believe you have a claim against the plaintiff, you must file a counterclaim with the Court and must serve

the plaintiff and all other parties with a copy of the Counterclaim at least seven days prior to the date of the trial of the plaintiff's claim.

A trial will be held on the date and time specified below, at the Court, 226 West Columbus Avenue,

Bellefontaine, Ohio. Telephone 937-599-6120.

THURSDAY, ______at 3:00 p.m. ______

Clerk/Deputy Clerk of Courts