Introduction

A Statement of Claim Form is a legal document filed in court to initiate a lawsuit. It outlines the plaintiff’s case against the defendant, detailing the facts of the case, the legal basis for the claim, and the relief sought. Understanding how to properly fill out a Statement of Claim Form is crucial for anyone looking to pursue legal action. Below are three diverse examples that illustrate different contexts in which this form may be utilized.

Example 1: Personal Injury Case

In this scenario, a person has been injured in a car accident due to another driver’s negligence. This example demonstrates how to articulate the claim clearly and succinctly.

The claimant, Jane Doe, is filing a Statement of Claim against John Smith, the driver responsible for the accident. The document outlines the details of the accident, the injuries sustained, and the compensation sought for medical expenses and pain and suffering.

“In the Circuit Court of City County

Jane Doe, Plaintiff

vs.

John Smith, Defendant

1. This Statement of Claim is submitted in relation to an accident that occurred on January 15, 2023, at the intersection of Main St. and 2nd Ave.

2. Plaintiff claims that Defendant was driving recklessly, resulting in a collision that caused her physical injuries, including a broken arm and whiplash.

3. Plaintiff seeks compensatory damages totaling $50,000 for medical bills, lost wages, and emotional distress.

4. Plaintiff requests a jury trial.”

Notes:

• Ensure all relevant details such as dates, locations, and specific injuries are included.
• Attach medical records and any evidence supporting the claim when filing.

Example 2: Breach of Contract

This example illustrates a situation where a business is filing a claim for breach of contract against a supplier who did not deliver goods as promised.

The business, ABC Corp, claims that the supplier, XYZ Supplies, failed to deliver materials needed for a project, resulting in financial losses.

“In the District Court of Business City

ABC Corp, Plaintiff

vs.

XYZ Supplies, Defendant

1. This Statement of Claim is filed regarding a contract dated March 1, 2023, where Defendant agreed to supply materials worth $20,000 by April 1, 2023.

2. Plaintiff claims that Defendant failed to deliver the materials on the agreed date, causing project delays and financial harm.

3. Plaintiff seeks damages of $25,000, which includes lost profits and additional costs incurred due to the delay.

4. Plaintiff requests a bench trial.”

Notes:

• Attach a copy of the contract and any correspondence that demonstrates the breach.
• Clearly specify the amount being claimed and the basis for calculating damages.

Example 3: Eviction Notice

In this scenario, a landlord is filing a Statement of Claim to evict a tenant who has failed to pay rent. This example highlights the specific grounds for eviction.

The landlord, Mary Johnson, is initiating eviction proceedings against her tenant, Tom Brown, due to non-payment of rent for three consecutive months.

“In the Housing Court of Rent City

Mary Johnson, Plaintiff

vs.

Tom Brown, Defendant

1. This Statement of Claim is filed regarding a lease agreement dated January 1, 2022, where the Defendant agreed to pay monthly rent of $1,200.

2. Plaintiff claims that Defendant has failed to pay rent for the months of July, August, and September 2023, totaling $3,600.

3. Plaintiff seeks possession of the property located at 123 Main St. and an order for the Defendant to vacate the premises.

4. Plaintiff requests a court date for eviction proceedings.”

Notes:

• Include a copy of the lease agreement and any notices given to the tenant regarding overdue rent.
• Ensure compliance with local laws regarding eviction processes.

Each of these examples illustrates how to effectively use a Statement of Claim Form in different legal contexts. Properly filling out this form is an essential step in pursuing legal action and ensuring your case is presented accurately to the court.