Statement of Small Claim 
and Notice of Trial

FOR
COURT 
USE ONLY 

(cid:2)

DOCKET NO. 

Trial Court of Massachusetts 
Small Claims Session

BOSTON MUNICIPAL COURT 

       DISTRICT COURT 

       HOUSING COURT 

___________________ Division 

_________________________Division 

_________________________Division 

PLAINTIFF’S NAME, ADDRESS, ZIP CODE AND PHONE 

PLAINTIFF’S ATTORNEY (If any)

_____________________________________
_____________________________________
_____________________________________ 

Name: ________________________________
Address:________________________________
          ________________________________

U S EBE

PHONE NO: 

PHONE NO:

BBO NO: 

DEFENDANT’S NAME, ADDRESS, ZIP CODE AND PHONE 

ADDITIONAL DEFENDANTS (If, any)

PART 
3

_____________________________________
_____________________________________
_____________________________________ 

Name: ________________________________
_________
Address:________________________________
_______
______
________
          ________________________________

________
________

PHONE NO: 

PLAINTIFF’S CLAIM. The defendant owes $_________ plus $________ court costs for the following reasons: 
Give the date of the event that is the basis of your claim. 

following reas
e following reas

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

__

__

_____

________

PHONE NO: 

______
___________

____________

_____________

_____________

F O R
____________R
N O T ____
                E, ______
defendant(s) is (aM P L E,                             
E,
L E
A M

attempt to
ng to attempt to sett

defendant(s) is (are

__________
____________

__________
__________

_____

SIGNATURE OF PLAINTIFF  X                                                                                                                                    DATE 

MEDIATION: Mediation of this claim may be available prior to trial if both parties agree to discuss the matter with a mediator, who will assist the 
may be availabl
may be available p
pute on mutually ag
parties in trying to resolve the dispute on mutually agreed to terms. The plaintiff must notify the court if he or she desires mediation; the defendant 
pute on mutually 
trial date
e trial date.
may consent to mediation on the trial date. 

MILITARY AFFIDAVIT: The plaintiff states under the pains and penalties of perjury that the: 

VIT: The plaintiff
VIT: The plaintiff sta

           The plaintiff is willing to attempt to settle this claim through court mediation. 

PART 
6

            above defendant(s) is (are) not serving in the military and at                                  above defendant(s) is (are) serving in the military. 
            present live(s) or work(s) at the above address.              

ent live(s) or 
ent live(s) or work(s

SIGNATURE OF PLAINTIFF  X                                                                                                                                    DATE                  

F PLA
OF PLAINT

S

NAME AND ADDRESS OF COURT 

(cid:3)  COURT USE ONLY  (cid:3)

BOTH THE 
PLAINTIFF 
AND THE 
DEFENDANT 
MUST 
APPEAR AT 
THIS COURT 
ON THE 
DATE AND 
TIME 
SPECIFIED 

DATE AND TIME OF TRIAL 

_________________  AT  ________________ 
DATE                                   TIME 

ROOM NO. 

NOTICE TO DEFENDANT: 
     You are being sued in Small Claims Court by the above named 
plaintiff. You are directed to appear for trial of this claim on the date 
and time noted to the right. 

     If you wish to settle this claim before the trial date, you should 
contact the plaintiff or the plaintiff’s attorney. 

SEE ADDITIONAL INSTRUCTIONS ON THE BACK OF THIS FORM. 

FIRST JUSTICE 

CLERK-MAGISTRATE OR DESIGNEE 

PART 
1

PART 
2

PART 
4

PART 
5

NOTICE OF TRIAL      

INSTRUCTIONS FOR FILING A SMALL CLAIM – You must complete Parts 1-6 of this form. See instructions on reverse. 

Statement of Small Claim and Notice of Trial  English  08/2012              www.mass.gov/courts/forms 

                                       

 

This document was developed under Grant 11-T-162 of the State Justice Institute.  The form does not necessarily represent the official position or policies of the State Justice Institute.