Best examples of 3 examples of statement of claim form (with real wording)

3 core examples of statement of claim form you can model

Most courts worldwide use the same basic structure for a statement of claim: parties, facts, legal basis, and what you’re asking for (the remedy). To make this concrete, here are three core examples of 3 examples of statement of claim form that people actually file in civil courts:

• a simple money claim for unpaid invoices,
• a personal injury claim after a car accident, and
• a wrongful termination claim in an employment dispute.

From there, I’ll expand into more scenarios so you end up with more than just 3 – you’ll see multiple real examples and variations you can borrow from.

Example of statement of claim for unpaid invoice (small business vs. client)

This is one of the best examples of a straightforward civil claim: a business did the work, the client didn’t pay. Here’s how the core of the statement might look in plain text.

Parties
Plaintiff: ABC Design LLC, a limited liability company organized under the laws of [State].
Defendant: John Smith, an individual residing in [County, State].

Facts

1. On or about March 1, 2024, Plaintiff and Defendant entered into a written contract for website design services for a total fee of $7,500.
2. Plaintiff completed the agreed services by April 15, 2024, and delivered the final website to Defendant.
3. Plaintiff issued Invoice #2024‑0315 in the amount of $7,500, due within 30 days.
4. Defendant has failed and refused to pay any portion of the invoice despite repeated written demands dated May 20, 2024, June 10, 2024, and July 1, 2024.

Cause of action – Breach of contract

5. Plaintiff and Defendant entered into a valid and enforceable contract.
6. Plaintiff fully performed its obligations under the contract.
7. Defendant breached the contract by failing to pay the agreed fee.
8. As a direct result, Plaintiff has suffered damages of $7,500 plus interest.

Relief sought
Plaintiff requests judgment against Defendant for:

• $7,500 in unpaid fees,
• pre‑ and post‑judgment interest as allowed by law, and
• costs of this action and any other relief the Court deems proper.

If you’re looking for examples of 3 examples of statement of claim form that are easy to adapt, this unpaid‑invoice structure is a good starting point for any simple debt or money owed situation.

Example of statement of claim for car accident personal injury

Personal injury cases add more moving parts: negligence, medical treatment, and ongoing losses. Among the best examples of a more detailed statement of claim form, a car accident claim usually includes facts about the crash, the injuries, and the defendant’s careless behavior.

Parties
Plaintiff: Maria Lopez, an individual residing in [County, State].
Defendant: David Brown, an individual residing in [County, State].

Facts

1. On September 5, 2024, at approximately 4:30 p.m., Plaintiff was lawfully operating her vehicle eastbound on Main Street near the intersection with 5th Avenue in [City, State].
2. Defendant was operating a vehicle directly behind Plaintiff in the same lane of travel.
3. Plaintiff stopped at a red traffic signal at the intersection.
4. Defendant, while distracted by using a mobile phone, failed to stop and violently rear‑ended Plaintiff’s vehicle.
5. As a result of the collision, Plaintiff sustained injuries to her neck, back, and left shoulder and was transported by ambulance to [Hospital Name].
6. Plaintiff has incurred medical expenses in excess of $18,000 to date and continues to receive treatment.
7. Plaintiff has also lost approximately six weeks of wages and continues to suffer pain, limitations in daily activities, and emotional distress.

Cause of action – Negligence

8. Defendant owed Plaintiff a duty to operate his vehicle with reasonable care.
9. Defendant breached that duty by failing to keep a proper lookout, failing to maintain a safe distance, and operating his vehicle while distracted by a mobile device.
10. Defendant’s negligence directly and proximately caused the collision and Plaintiff’s injuries.
11. Plaintiff has suffered economic and non‑economic damages, including medical expenses, lost wages, pain and suffering, and loss of enjoyment of life.

Relief sought
Plaintiff requests judgment against Defendant for:

• medical expenses (past and future) according to proof,
• lost wages and loss of earning capacity,
• damages for pain and suffering, and
• costs of suit and any other relief the Court finds just.

For readers comparing examples of 3 examples of statement of claim form, this personal injury version shows how to connect specific facts (date, place, injuries) to the legal theory (negligence) and then to the remedy.

Example of statement of claim for wrongful termination (employment)

Employment cases are another category where people actively search for real examples of statement of claim form language. Here’s a streamlined sample for a wrongful termination claim under state law.

Parties
Plaintiff: Daniel Green, an individual residing in [County, State].
Defendant: TechNova Inc., a corporation organized under the laws of [State].

Facts

1. Plaintiff was employed by Defendant as a software engineer from June 1, 2020, until his termination on January 10, 2025.
2. During his employment, Plaintiff consistently received positive performance evaluations and merit‑based raises.
3. In October 2024, Plaintiff reported to Human Resources that his direct supervisor was instructing his team to falsify project status reports provided to a major client.
4. Plaintiff refused to participate in falsifying reports and reiterated his concerns in a written complaint dated November 5, 2024.
5. On January 10, 2025, Defendant terminated Plaintiff’s employment, citing “restructuring,” despite no comparable layoffs in Plaintiff’s department.
6. Plaintiff believes he was terminated in retaliation for reporting and refusing to participate in unlawful conduct.

Cause of action – Wrongful termination in violation of public policy

7. Plaintiff engaged in protected activity by reporting and refusing to participate in unlawful business practices.
8. Defendant knew of Plaintiff’s protected activity.
9. Defendant terminated Plaintiff’s employment in retaliation for that activity.
10. Defendant’s conduct violates the public policy of [State], including statutes prohibiting fraud and retaliation against whistleblowers.
11. As a result, Plaintiff has suffered lost wages, lost benefits, emotional distress, and harm to his professional reputation.

Relief sought
Plaintiff requests judgment against Defendant for:

• back pay and front pay,
• lost benefits,
• damages for emotional distress,
• punitive damages as permitted by law, and
• attorney’s fees, costs, and any other relief the Court deems proper.

If you’re comparing examples of 3 examples of statement of claim form for workplace disputes, this one highlights how retaliation and public policy language typically show up.

More real examples: property damage, landlord–tenant, and consumer claims

Three scenarios are not enough for the real world, so let’s expand beyond the initial 3 examples of statement of claim form to show how the same structure works in other disputes.

Property damage from a contractor’s work

Scenario: A homeowner hires a contractor to remodel a kitchen. Faulty plumbing work causes flooding and damage.

Sample wording (core parts):

• Plaintiff alleges that on or about August 1, 2024, Defendant installed new plumbing fixtures in Plaintiff’s residence.
• On August 10, 2024, a pipe installed by Defendant burst, causing extensive water damage to Plaintiff’s cabinets, flooring, and drywall.
• Plaintiff’s independent inspection revealed that Defendant failed to install the pipe fittings according to manufacturer specifications and applicable building codes.
• Plaintiff seeks damages for repair costs, temporary housing, and related expenses.

This is one of the best examples of a property‑damage‑focused statement of claim form: it ties faulty workmanship to specific, documented losses.

Landlord–tenant: return of security deposit

Scenario: Tenant moves out, landlord keeps the entire security deposit without valid reason.

Sample wording (core parts):

• Plaintiff entered into a residential lease with Defendant on June 1, 2023, and paid a $1,500 security deposit.
• Plaintiff vacated the property on May 31, 2024, after providing proper notice and leaving the premises clean and undamaged, normal wear and tear excepted.
• Defendant failed to return any portion of the security deposit within the time required by [State] law and failed to provide an itemized statement of deductions.
• Plaintiff seeks return of the $1,500 deposit, statutory penalties, and court costs.

This fits neatly alongside the other examples of 3 examples of statement of claim form because it uses the same bones: facts, legal duty, violation, and remedy.

Consumer claim: defective product and refund

Scenario: A consumer buys a high‑end appliance that repeatedly fails, and the seller refuses refund or replacement.

Sample wording (core parts):

• On March 12, 2024, Plaintiff purchased a [Brand/Model] refrigerator from Defendant for $2,100.
• Within three months, the refrigerator experienced multiple failures, including loss of cooling, spoiled food, and repeated service calls.
• Despite Plaintiff’s timely warranty claims, Defendant failed to repair or replace the refrigerator and refused to issue a refund.
• Plaintiff asserts claims for breach of express warranty and breach of implied warranty of merchantability, seeking a refund, incidental damages, and costs.

For readers looking for real examples of 3 examples of statement of claim form that apply to everyday life, this consumer‑goods scenario is highly adaptable.

How courts expect a statement of claim form to be structured

Whether you’re in a U.S. state court, a Canadian provincial court, or another common‑law system, the pattern behind all these examples of 3 examples of statement of claim form is similar:

• Caption and parties – Who is suing whom, and in what court.
• Jurisdiction and venue – Why this court is the right place (often a short paragraph).
• Material facts – Chronological, numbered paragraphs telling the story.
• Causes of action – Each legal theory (breach of contract, negligence, etc.) in its own labeled section.
• Relief sought – What you want the court to award or order.

Many courts publish their own civil complaint or claim forms. For example, U.S. federal courts provide a standard civil complaint form (Pro Se 1) on the U.S. Courts website, and state courts often have similar resources on their own .gov portals.

When you look at the best examples of 3 examples of statement of claim form, you’ll notice they:

• avoid emotional rants and stick to facts,
• number paragraphs for clarity, and
• connect each fact to a legal consequence and a specific request.

2024–2025 trends that affect how you draft your claim

Recent years have quietly changed how people prepare and file these forms:

1. E‑filing and online portals
More courts now require electronic filing. That means:

• You may need to upload your statement of claim form as a PDF through a portal.
• Some systems limit file size or require specific formatting.
  Check your court’s website (for example, many state courts link e‑filing rules from their main judiciary pages on .gov domains).

2. Self‑represented litigants ("pro se” or “pro per")
Data from U.S. courts show a steady presence of self‑represented parties in civil cases. In response, many courts now:

• publish plain‑language instructions,
• offer fill‑in‑the‑blank civil complaint forms, and
• host self‑help centers or clinics.
  A useful starting point is the USA.gov legal help page, which links to legal aid and court self‑help resources.

3. Remote hearings and hybrid procedures
Post‑pandemic, many courts still conduct status conferences or minor hearings by video. Your statement of claim form may be reviewed on screen by a judge who has dozens of cases that day. Clear headings, short paragraphs, and organized facts matter more than ever.

These shifts don’t change the legal requirements, but they do change how readable your claim needs to be. If you study recent online court examples of 3 examples of statement of claim form, you’ll see a trend toward cleaner, more structured drafting.

Practical tips when using these examples

Using these real examples of 3 examples of statement of claim form as a model is smart, but copying them word‑for‑word without tailoring them is not.

A few practical guidelines:

• Match your jurisdiction. Every court has its own rules about formatting, page limits, and required forms. Check your local court’s website or self‑help center.
• Use your own facts. Replace placeholder dates, amounts, and descriptions with your actual timeline and evidence.
• Be consistent with names and dates. Judges notice when names are misspelled or dates don’t line up.
• Don’t guess at legal claims. If you’re not sure whether your situation is negligence, breach of contract, or something else, talk to a lawyer or at least review a reputable legal aid guide.

For background on civil cases and procedures in the U.S., the U.S. Courts "Understanding the Federal Courts" section offers accessible overviews that can help you see where your statement of claim fits into the bigger picture.

FAQ about statement of claim forms and examples

Q1. Can I use these as direct examples of a statement of claim form and just change the names?
You can use them as a starting point, but you should not just swap names and file. Laws differ from state to state and country to country. The best practice is to treat these as educational examples of 3 examples of statement of claim form, then adapt the structure and wording to your jurisdiction and facts, ideally with legal advice.

Q2. Where can I see official examples of court complaint or claim forms?
Many courts publish sample forms. In the U.S., the federal judiciary’s civil forms page includes a standard complaint form that shows you how courts expect information to be organized. State and local courts often have similar templates on their .gov websites under “forms” or “self‑help.”

Q3. What is an example of something people often forget to include in a statement of claim?
People frequently forget to clearly state the relief sought. Your form should not just say what went wrong; it should say exactly what you want the court to award (money, specific performance, an order to do or stop doing something). Look back at the unpaid invoice and personal injury examples of 3 examples of statement of claim form above and notice how the relief section is spelled out.

Q4. Do I have to cite statutes and case law in my statement of claim?
In many lower‑level civil courts, especially small claims, you’re not required to cite statutes or case law. You mostly need clear facts and a plain statement of your claim. In higher courts, lawyers often add statutory references. If you’re unsure, check your court’s instructions or consult a local attorney.

Q5. Can I file a statement of claim without a lawyer?
Often yes, especially in small claims or lower‑value civil cases. But the more complex your dispute (employment law, serious injury, large contracts), the more risky it is to proceed alone. If you’re going to rely on online examples of 3 examples of statement of claim form, at least consider a short consultation with an attorney or a legal aid clinic to review your draft.

Bottom line: studying real‑world style wording across several different disputes gives you far more value than a single generic template. Use these unpaid invoice, personal injury, employment, property damage, landlord–tenant, and consumer‑goods examples as a reference point, then build a statement of claim that accurately reflects your facts, in your court, under your law.