CITY COURT of __________________   :   COUNTY OF ______________________
25 Court Street
Cortland, NY 13045
Ph.: 607-753-1811

Index #C ___________________________________

FILING FEE:     Cash, Money Order, Certified Bank Checks, or Credit Card (No Personal or Business Checks accepted)

Type of Claim:                                                  Filing Fee:                                                            (Check one)
Small Claim                                                        $15.00 - Claim of $1,000 or less                            _____
   (Individual suing individual or company)           $20.00 - Claim exceeding $1,000 to $5,000           _____

Commercial Claim                                             $25.00 + $5.74 postage                                          _____
  (Company suing company or individual)
   (Required forms - Certificate of Authority and Certification on Filing Limits)

Counterclaim                                                       $  5.00 + $ .42 postage                                         _____

Date:     ___________________________________
Name of Claimant (include all necessary parties):    _______________________________________________________
________________________________________________________________________________________________
Address (if commercial claim, give Principal Office Address)
Telephone no.: ___________________________________________________________________________________
                                         (Work)                                                         (Home)
                                                                                      against
Name of Defendant (include all necessary parties):    _______________________________________________________
                                    (if a business -provide business name AND name of  individual who owns/operates/manages business)
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Address (Home or Business./Place of Employment must be within the County - except for counterclaims)     (Telephone no.)

Amount of Claim $__________________________   (Do not include filing fee)

Nature of Claim to include all pertinent information including descriptions, dates, addresses, etc.
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DATE:                                                                                               SIGNATURE OF PERSON FILING CLAIM