Form JD-CV-40 "Small Claims Writ and Notice of Suit" - Connecticut

What Is Form JD-CV-40?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2019;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-CV-40 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-CV-40 "Small Claims Writ and Notice of Suit" - Connecticut

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Instructions to Plaintiff
3. Claim Between Landlord and Tenant (Renter)
The “Small Claims Court” is a part of Connecticut's court system
where a person can sue for money damages only up to $5,000.
If the claim is between a landlord and a renter (tenant), then
That amount is set by state law and may change from time to time.
select the box for "Yes". If not, then select the box for "No".
You may also be able to get interest and costs.
4. Rental Property Location
When a tenant (renter) of residential real estate property sues a
If you answered "Yes" to question 3, then write the name of the
landlord for the return of a wrongfully withheld security deposit, the
town where the rental property is located.
Judicial Authority (Magistrate) may award the tenant twice the
5. Plaintiff(s)
amount of the security deposit even if the total amount of damages
You are the plaintiff because you are the person suing the other
and costs, combined, is greater than $5,000. Read sections 51-15(d)
party. If there is more than 1 plaintiff, use the Continuation of
and 47a-21 of the Connecticut General Statutes for more information.
Parties (form JD-CV-67). Enter the complete and correct legal
The small claims court does not hear libel and slander cases.
name, address, and telephone number of each plaintiff. For
each plaintiff, select the box for the type of plaintiff filing.
The instructions below are numbered. The numbers are the same as
the numbered sections of the Small Claims Writ and Notice of Suit
6. Attorney Information
(form JD-CV-40). These instructions are to help you correctly fill out
To be filled out by an attorney only if representing the plaintiff.
each section of the Small Claims Writ and Notice of Suit. For more
7. Defendant(s)
information, get a copy of How Small Claims Court Works
The defendant is the person you are suing. If you are suing
(form JDP-CV-45) from the Clerk's Office or from our website at
more than 1 person, use 1 box for each defendant. For more
www.jud.ct.gov/faq/smallclaims.html.
than 2 defendants, use the Continuation of Parties
Note: Unless you are hiring a state marshal to serve (deliver) the
(form JD-CV-67). Enter the complete and correct legal name,
Small Claims Writ and Notice of Suit for you, you must deliver a copy
address, and telephone number of each defendant. For each
of the completed original Small Claims Writ and Notice of Suit to
defendant, select the box for the type of defendant being sued.
Note: The name of the person or business you are suing must
each defendant with the Instructions to Defendant (form JD-CV-121),
before filing those documents with the court. See How to Serve
be exact. If you make a mistake and list the wrong name, or
(Deliver to Defendant) a Small Claim Writ and Notice of Suit (form
leave out any part of any name, your claim may not be allowed.
JD-CV-122) for instructions. You must deliver a copy of all the
8. Statute of Limitations
documents you want to file with the court, for example, all
A statute of limitations is a time limit on how long you have to
attachments to the original writ must be delivered. After all of those
start a case. The time limit is different for each type of case.
documents have been delivered, file the original Small Claims Writ
More information can be found in Chapter 926 of the
and Notice of Suit and copies of your supporting documents (for
Connecticut General Statutes. If you claim the defendant(s)
example, a lease or a contract) with the court, with the appropriate
owe(s) a consumer debt, which is a debt or obligation made
entry fee and Statement of Service (form JD-CV-123) for each
primarily for personal, family, or household reasons, you must
defendant. Keep a copy of the Small Claims Writ and Notice of Suit
give the reasons why you believe that the statute of limitations
and the Statement of Service for your records. Keep the original of
time limit has not run out. See section 52-350a(2) of the
any supporting documents.
Connecticut General Statutes.
1. Information That Will Determine Where The Trial Will Be
9. Address Verification
The information you give in this section will determine where the
Select all boxes that apply showing how you know the address
trial will be held as long as the information complies with the law.
you give for each defendant is accurate and provide the date
If you are suing as a Landlord or Tenant, enter the town where
you checked the addresses.
the rental property is located.
10. Amount Claimed
If you are an Individual Plaintiff, choose and enter one of the
Enter the amount of money you are claiming the defendant
following: the town (a) where you live, (b) where the defendant
owes you. The amount may not be more than the statutory limit
lives or where the defendant's business is located, or (c) where the
for small claims matters. If you claim pre-judgment interest or
that you should be awarded double damages because you are
transaction or injury occurred. If you leave this section blank, the
town where you live will determine the trial location.
a tenant and your landlord wrongfully withheld your security
deposit, select the box(es) that apply.
If you are a Business Entity, including a domestic or United
States corporation or a limited liability company, choose and enter
Do not include the filing fee, amount of pre-judgment interest,
one of the following: the town (a) where the defendant lives,
or double damages for a wrongfully withheld security deposit.
(b) where the defendant is doing business, or (c) where the
11. Reason for Claim
transaction or injury occurred. If you leave this section blank, the
Give a clear, brief description of your case. You may attach
town where the defendant lives will determine the trial location.
additional pages, if needed. The claim must be for money
Note: An out-of-state Individual Defendant must own real or
damages only. Interest and/or the amount for double damages
for a wrongfully withheld security deposit must be listed in this
personal property in Connecticut to be sued in small claims court.
section. You may attach exhibits or documents to support your
2. Case Type Codes:
case (for example, a lease or contract). However, do not attach
The small claims case type code will contain a major code, which
original versions; attach only copies. Attachments may not be
will be either S or H, and a minor code, which will be a number.
returned to you. You may bring original documents to your
Select the code that best describes your case:
hearing.
Code
Description
12. Signature and Oath
S00
Small Claims - Collection - Credit Card (Original Owner)
Your signature must be under oath. You must sign the writ in
S05
Small Claims - Collection - Hospital
front of the person who is taking your oath. You must also
S10
Small Claims - Collection - Medical Non-Hospital
clearly print your name and title, if applicable, in the box
S15
Small Claims - Collection - Purchased Debt
provided. Your oath must be taken at the time you sign the writ,
S20
Small Claims - Contract - Home Improvement
and the person who took your oath (the Clerk, a Notary, or a
S25
Small Claims - Contract - Other
Commissioner of the Superior Court) must also sign. Attorneys
S50
Small Claims - Tort - Motor Vehicle
are Commissioners of the Superior Court.
S55
Small Claims - Tort - Other
S90
Small Claims - All Other
Keep a copy of all documents for your records.
H11
Small Claims Housing - Return of Security Deposit
H13
Small Claims Housing - Rent and/or Damages
Print Form
Reset Form
Page 1 of 5
JD-CV-40 (Back) Rev. 9-19
Instructions to Plaintiff
3. Claim Between Landlord and Tenant (Renter)
The “Small Claims Court” is a part of Connecticut's court system
where a person can sue for money damages only up to $5,000.
If the claim is between a landlord and a renter (tenant), then
That amount is set by state law and may change from time to time.
select the box for "Yes". If not, then select the box for "No".
You may also be able to get interest and costs.
4. Rental Property Location
When a tenant (renter) of residential real estate property sues a
If you answered "Yes" to question 3, then write the name of the
landlord for the return of a wrongfully withheld security deposit, the
town where the rental property is located.
Judicial Authority (Magistrate) may award the tenant twice the
5. Plaintiff(s)
amount of the security deposit even if the total amount of damages
You are the plaintiff because you are the person suing the other
and costs, combined, is greater than $5,000. Read sections 51-15(d)
party. If there is more than 1 plaintiff, use the Continuation of
and 47a-21 of the Connecticut General Statutes for more information.
Parties (form JD-CV-67). Enter the complete and correct legal
The small claims court does not hear libel and slander cases.
name, address, and telephone number of each plaintiff. For
each plaintiff, select the box for the type of plaintiff filing.
The instructions below are numbered. The numbers are the same as
the numbered sections of the Small Claims Writ and Notice of Suit
6. Attorney Information
(form JD-CV-40). These instructions are to help you correctly fill out
To be filled out by an attorney only if representing the plaintiff.
each section of the Small Claims Writ and Notice of Suit. For more
7. Defendant(s)
information, get a copy of How Small Claims Court Works
The defendant is the person you are suing. If you are suing
(form JDP-CV-45) from the Clerk's Office or from our website at
more than 1 person, use 1 box for each defendant. For more
www.jud.ct.gov/faq/smallclaims.html.
than 2 defendants, use the Continuation of Parties
Note: Unless you are hiring a state marshal to serve (deliver) the
(form JD-CV-67). Enter the complete and correct legal name,
Small Claims Writ and Notice of Suit for you, you must deliver a copy
address, and telephone number of each defendant. For each
of the completed original Small Claims Writ and Notice of Suit to
defendant, select the box for the type of defendant being sued.
Note: The name of the person or business you are suing must
each defendant with the Instructions to Defendant (form JD-CV-121),
before filing those documents with the court. See How to Serve
be exact. If you make a mistake and list the wrong name, or
(Deliver to Defendant) a Small Claim Writ and Notice of Suit (form
leave out any part of any name, your claim may not be allowed.
JD-CV-122) for instructions. You must deliver a copy of all the
8. Statute of Limitations
documents you want to file with the court, for example, all
A statute of limitations is a time limit on how long you have to
attachments to the original writ must be delivered. After all of those
start a case. The time limit is different for each type of case.
documents have been delivered, file the original Small Claims Writ
More information can be found in Chapter 926 of the
and Notice of Suit and copies of your supporting documents (for
Connecticut General Statutes. If you claim the defendant(s)
example, a lease or a contract) with the court, with the appropriate
owe(s) a consumer debt, which is a debt or obligation made
entry fee and Statement of Service (form JD-CV-123) for each
primarily for personal, family, or household reasons, you must
defendant. Keep a copy of the Small Claims Writ and Notice of Suit
give the reasons why you believe that the statute of limitations
and the Statement of Service for your records. Keep the original of
time limit has not run out. See section 52-350a(2) of the
any supporting documents.
Connecticut General Statutes.
1. Information That Will Determine Where The Trial Will Be
9. Address Verification
The information you give in this section will determine where the
Select all boxes that apply showing how you know the address
trial will be held as long as the information complies with the law.
you give for each defendant is accurate and provide the date
If you are suing as a Landlord or Tenant, enter the town where
you checked the addresses.
the rental property is located.
10. Amount Claimed
If you are an Individual Plaintiff, choose and enter one of the
Enter the amount of money you are claiming the defendant
following: the town (a) where you live, (b) where the defendant
owes you. The amount may not be more than the statutory limit
lives or where the defendant's business is located, or (c) where the
for small claims matters. If you claim pre-judgment interest or
that you should be awarded double damages because you are
transaction or injury occurred. If you leave this section blank, the
town where you live will determine the trial location.
a tenant and your landlord wrongfully withheld your security
deposit, select the box(es) that apply.
If you are a Business Entity, including a domestic or United
States corporation or a limited liability company, choose and enter
Do not include the filing fee, amount of pre-judgment interest,
one of the following: the town (a) where the defendant lives,
or double damages for a wrongfully withheld security deposit.
(b) where the defendant is doing business, or (c) where the
11. Reason for Claim
transaction or injury occurred. If you leave this section blank, the
Give a clear, brief description of your case. You may attach
town where the defendant lives will determine the trial location.
additional pages, if needed. The claim must be for money
Note: An out-of-state Individual Defendant must own real or
damages only. Interest and/or the amount for double damages
for a wrongfully withheld security deposit must be listed in this
personal property in Connecticut to be sued in small claims court.
section. You may attach exhibits or documents to support your
2. Case Type Codes:
case (for example, a lease or contract). However, do not attach
The small claims case type code will contain a major code, which
original versions; attach only copies. Attachments may not be
will be either S or H, and a minor code, which will be a number.
returned to you. You may bring original documents to your
Select the code that best describes your case:
hearing.
Code
Description
12. Signature and Oath
S00
Small Claims - Collection - Credit Card (Original Owner)
Your signature must be under oath. You must sign the writ in
S05
Small Claims - Collection - Hospital
front of the person who is taking your oath. You must also
S10
Small Claims - Collection - Medical Non-Hospital
clearly print your name and title, if applicable, in the box
S15
Small Claims - Collection - Purchased Debt
provided. Your oath must be taken at the time you sign the writ,
S20
Small Claims - Contract - Home Improvement
and the person who took your oath (the Clerk, a Notary, or a
S25
Small Claims - Contract - Other
Commissioner of the Superior Court) must also sign. Attorneys
S50
Small Claims - Tort - Motor Vehicle
are Commissioners of the Superior Court.
S55
Small Claims - Tort - Other
S90
Small Claims - All Other
Keep a copy of all documents for your records.
H11
Small Claims Housing - Return of Security Deposit
H13
Small Claims Housing - Rent and/or Damages
Print Form
Reset Form
Page 1 of 5
JD-CV-40 (Back) Rev. 9-19
SMALL CLAIMS WRIT
STATE OF CONNECTICUT
AND NOTICE OF SUIT
SUPERIOR COURT
JD-CV-40
Rev. 9-19
SMALL CLAIMS SESSION
C.G.S. §§ 51-15, 51-345(g)
www.jud.ct.gov
Type or print legibly. This Small Claims Writ and Notice of Suit must be served on (delivered to)
the defendant(s) before filing it with the court. See Instructions to Plaintiff on reverse.
1.) Location information that will determine where the trial will be:
2.) Case type code (See list on reverse page 1)
Major:
Minor:
3.) Is this a claim between a landlord and a tenant (renter)?
4.) If you answered "Yes" to question #3, state the town where the rental premises is located:
(Select one)
Yes
No
Parties
Name (Last, First, Middle Initial) and Address of Each Party (Number; Street; P.O. Box; Town; State; Zip; Country, if not USA)
Name:
(Select one)
LLC
Partnership
5.) First
P-01
Address:
Plaintiff
Individual
DBA
Corporation
Telephone:
Attorney's Juris Number
Telephone number (w/area code)
6.) Name, address, and zip code of Attorney for Plaintiff(s)
Name:
(Select one)
LLC
Partnership
7.) First
D-01
Address:
Defendant
Individual
DBA
Corporation
Telephone:
For more than 1 plaintiff/defendant, attach Continuation of Parties (form JD-CV-67) and select this box.
8.) If this claim is a consumer debt, which is a debt or obligation made primarily for personal, family, or household reasons, give the reasons why you believe
that the statute of limitations has not expired.
9.) How did you check in the last 6 months that the address given for defendant(s) is accurate?
Select all boxes that apply and provide the dates that the address was checked.
I checked town or city records (for example, checking a street list or tax records)
(date checked)
I checked with the Department of Motor Vehicles
(date checked)
I received correspondence (letters or other mail) from the defendant with that return address
(date checked)
I received other proof from the defendant that the address is current
(description of proof
and date checked)
I mailed by first class mail, at least 4 weeks before this small claims action was filed, a letter to the defendant at the
(last date checked
address used and the letter has not been returned to me by the United States Postal Service
for returned letter)
10.) Amount claimed*
Plus pre-judgment interest**
Plus Costs
Plus double damages for security deposit withheld**
*The Amount Claimed may not be more than $5,000. Do not include amounts
**If you select one or more boxes, you MUST explain
for pre-judgment interest or doubling the security deposit in box 10.
how much you want for each item in section 11 below.
To Defendant(s):
11.) You are being sued. The Plaintiff(s) claims you owe the above amount plus costs and pre-judgment interest and/or double damages for a withheld
security deposit (if selcted) for the following reasons:
The person signing below, being duly sworn, states that he or she has read the claim above and the information contained in this form and, to the best of his
or her knowledge, information and belief, there is good ground to support the claim and the information is true.
Type in name of person signing at left and title, if applicable
For Court Use Only (Date/Stamp)
12.) Signed
Date
Signed (Clerk, Notary, Commissioner of the Superior Court)
Subscribed and
sworn to before me on
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
Docket Number
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Print Form
Reset Form
Page 2 of 5
SMALL CLAIMS WRIT
STATE OF CONNECTICUT
AND NOTICE OF SUIT
SUPERIOR COURT
JD-CV-40
Rev. 9-19
SMALL CLAIMS SESSION
C.G.S. §§ 51-15, 51-345(g)
www.jud.ct.gov
Type or print legibly. This Small Claims Writ and Notice of Suit must be served on (delivered to)
the defendant(s) before filing it with the court. See Instructions to Plaintiff on reverse.
1.) Location information that will determine where the trial will be:
2.) Case type code (See list on reverse page 1)
Major:
Minor:
3.) Is this a claim between a landlord and a tenant (renter)?
4.) If you answered "Yes" to question #3, state the town where the rental premises is located:
(Select one)
Yes
No
Parties
Name (Last, First, Middle Initial) and Address of Each Party (Number; Street; P.O. Box; Town; State; Zip; Country, if not USA)
Name:
(Select one)
LLC
Partnership
5.) First
P-01
Address:
Plaintiff
Individual
DBA
Corporation
Telephone:
Attorney's Juris Number
Telephone number (w/area code)
6.) Name, address, and zip code of Attorney for Plaintiff(s)
Name:
(Select one)
LLC
Partnership
7.) First
D-01
Address:
Defendant
Individual
DBA
Corporation
Telephone:
For more than 1 plaintiff/defendant, attach Continuation of Parties (form JD-CV-67) and select this box.
8.) If this claim is a consumer debt, which is a debt or obligation made primarily for personal, family, or household reasons, give the reasons why you believe
that the statute of limitations has not expired.
9.) How did you check in the last 6 months that the address given for defendant(s) is accurate?
Select all boxes that apply and provide the dates that the address was checked.
I checked town or city records (for example, checking a street list or tax records)
(date checked)
I checked with the Department of Motor Vehicles
(date checked)
I received correspondence (letters or other mail) from the defendant with that return address
(date checked)
I received other proof from the defendant that the address is current
(description of proof
and date checked)
I mailed by first class mail, at least 4 weeks before this small claims action was filed, a letter to the defendant at the
(last date checked
address used and the letter has not been returned to me by the United States Postal Service
for returned letter)
10.) Amount claimed*
Plus pre-judgment interest**
Plus Costs
Plus double damages for security deposit withheld**
*The Amount Claimed may not be more than $5,000. Do not include amounts
**If you select one or more boxes, you MUST explain
for pre-judgment interest or doubling the security deposit in box 10.
how much you want for each item in section 11 below.
To Defendant(s):
11.) You are being sued. The Plaintiff(s) claims you owe the above amount plus costs and pre-judgment interest and/or double damages for a withheld
security deposit (if selcted) for the following reasons:
The person signing below, being duly sworn, states that he or she has read the claim above and the information contained in this form and, to the best of his
or her knowledge, information and belief, there is good ground to support the claim and the information is true.
Type in name of person signing at left and title, if applicable
For Court Use Only (Date/Stamp)
12.) Signed
Date
Signed (Clerk, Notary, Commissioner of the Superior Court)
Subscribed and
sworn to before me on
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
Docket Number
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Print Form
Reset Form
Page 3 of 5
SMALL CLAIMS WRIT
STATE OF CONNECTICUT
AND NOTICE OF SUIT
SUPERIOR COURT
JD-CV-40
Rev. 9-19
SMALL CLAIMS SESSION
C.G.S. §§ 51-15, 51-345(g)
www.jud.ct.gov
Type or print legibly. This Small Claims Writ and Notice of Suit must be served on (delivered to)
the defendant(s) before filing it with the court. See Instructions to Plaintiff on reverse.
1.) Location information that will determine where the trial will be:
2.) Case type code (See list on reverse page 1)
Major:
Minor:
3.) Is this a claim between a landlord and a tenant (renter)?
4.) If you answered "Yes" to question #3, state the town where the rental premises is located:
(Select one)
Yes
No
Parties
Name (Last, First, Middle Initial) and Address of Each Party (Number; Street; P.O. Box; Town; State; Zip; Country, if not USA)
Name:
(Select one)
LLC
Partnership
5.) First
P-01
Address:
Plaintiff
Individual
DBA
Corporation
Telephone:
Attorney's Juris Number
Telephone number (w/area code)
6.) Name, address, and zip code of Attorney for Plaintiff(s)
Name:
(Select one)
LLC
Partnership
7.) First
D-01
Address:
Defendant
Individual
DBA
Corporation
Telephone:
For more than 1 plaintiff/defendant, attach Continuation of Parties (form JD-CV-67) and select this box.
8.) If this claim is a consumer debt, which is a debt or obligation made primarily for personal, family, or household reasons, give the reasons why you believe
that the statute of limitations has not expired.
9.) How did you check in the last 6 months that the address given for defendant(s) is accurate?
Select all boxes that apply and provide the dates that the address was checked.
I checked town or city records (for example, checking a street list or tax records)
(date checked)
I checked with the Department of Motor Vehicles
(date checked)
I received correspondence (letters or other mail) from the defendant with that return address
(date checked)
I received other proof from the defendant that the address is current
(description of proof
and date checked)
I mailed by first class mail, at least 4 weeks before this small claims action was filed, a letter to the defendant at the
(last date checked
address used and the letter has not been returned to me by the United States Postal Service
for returned letter)
10.) Amount claimed*
Plus pre-judgment interest**
Plus Costs
Plus double damages for security deposit withheld**
*The Amount Claimed may not be more than $5,000. Do not include amounts
**If you select one or more boxes, you MUST explain
for pre-judgment interest or doubling the security deposit in box 10.
how much you want for each item in section 11 below.
To Defendant(s):
11.) You are being sued. The Plaintiff(s) claims you owe the above amount plus costs and pre-judgment interest and/or double damages for a withheld
security deposit (if selcted) for the following reasons:
The person signing below, being duly sworn, states that he or she has read the claim above and the information contained in this form and, to the best of his
or her knowledge, information and belief, there is good ground to support the claim and the information is true.
Type in name of person signing at left and title, if applicable
For Court Use Only (Date/Stamp)
12.) Signed
Date
Signed (Clerk, Notary, Commissioner of the Superior Court)
Subscribed and
sworn to before me on
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
Docket Number
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Print Form
Reset Form
Page 4 of 5
SMALL CLAIMS WRIT
STATE OF CONNECTICUT
AND NOTICE OF SUIT
SUPERIOR COURT
JD-CV-40
Rev. 9-19
SMALL CLAIMS SESSION
C.G.S. §§ 51-15, 51-345(g)
www.jud.ct.gov
Type or print legibly. This Small Claims Writ and Notice of Suit must be served on (delivered to)
the defendant(s) before filing it with the court. See Instructions to Plaintiff on reverse.
1.) Location information that will determine where the trial will be:
2.) Case type code (See list on reverse page 1)
Major:
Minor:
3.) Is this a claim between a landlord and a tenant (renter)?
4.) If you answered "Yes" to question #3, state the town where the rental premises is located:
(Select one)
Yes
No
Parties
Name (Last, First, Middle Initial) and Address of Each Party (Number; Street; P.O. Box; Town; State; Zip; Country, if not USA)
Name:
(Select one)
LLC
Partnership
5.) First
P-01
Address:
Plaintiff
Individual
DBA
Corporation
Telephone:
Attorney's Juris Number
Telephone number (w/area code)
6.) Name, address, and zip code of Attorney for Plaintiff(s)
Name:
(Select one)
LLC
Partnership
7.) First
D-01
Address:
Defendant
Individual
DBA
Corporation
Telephone:
For more than 1 plaintiff/defendant, attach Continuation of Parties (form JD-CV-67) and select this box.
8.) If this claim is a consumer debt, which is a debt or obligation made primarily for personal, family, or household reasons, give the reasons why you believe
that the statute of limitations has not expired.
9.) How did you check in the last 6 months that the address given for defendant(s) is accurate?
Select all boxes that apply and provide the dates that the address was checked.
I checked town or city records (for example, checking a street list or tax records)
(date checked)
I checked with the Department of Motor Vehicles
(date checked)
I received correspondence (letters or other mail) from the defendant with that return address
(date checked)
I received other proof from the defendant that the address is current
(description of proof
and date checked)
I mailed by first class mail, at least 4 weeks before this small claims action was filed, a letter to the defendant at the
(last date checked
address used and the letter has not been returned to me by the United States Postal Service
for returned letter)
10.) Amount claimed*
Plus pre-judgment interest**
Plus Costs
Plus double damages for security deposit withheld**
*The Amount Claimed may not be more than $5,000. Do not include amounts
**If you select one or more boxes, you MUST explain
for pre-judgment interest or doubling the security deposit in box 10.
how much you want for each item in section 11 below.
To Defendant(s):
11.) You are being sued. The Plaintiff(s) claims you owe the above amount plus costs and pre-judgment interest and/or double damages for a withheld
security deposit (if selcted) for the following reasons:
The person signing below, being duly sworn, states that he or she has read the claim above and the information contained in this form and, to the best of his
or her knowledge, information and belief, there is good ground to support the claim and the information is true.
Type in name of person signing at left and title, if applicable
For Court Use Only (Date/Stamp)
12.) Signed
Date
Signed (Clerk, Notary, Commissioner of the Superior Court)
Subscribed and
sworn to before me on
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
Docket Number
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
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