at 

  the court address above.

ate

 D

 
 
 
 
 
 

 

The plaintiff and the defendant must be in court on

at 

Time

 

Location

 

City, state, zip                                                                 Telephone no.

Process server’s name

  Fee paid: $ 
 

  3. A civil action between these parties or other parties arising out of the transaction or occurrence alleged in this 

    complaint has been previously filed in 

 

 this court 

 

 
 

 Court.

    It was given case number  
 

 and assigned to Judge 
 

    The action 

 

 remains 

 

 is no longer 

  pending. 

4. I have knowledge or belief about all the facts stated in this affidavit and I am
 

 the plaintiff or his/her guardian, conservator, or next friend. 

 a partner. 

 

 

 a full-time employee of the plaintiff.

5. The plaintiff is 

   

 an individual. 

 a partnership. 

 a corporation. 

 a sole proprietor. 

6. The defendant is 

 an individual. 

 a partnership. 

 a corporation. 

 a sole proprietor. 

 
 

 
 

7. The date(s) the claim arose is/are 

Attach separate sheets if necessary

                                                                                        They are not part of the amount claimed.)

 . (Note: Plaintiff’s costs are determined by the court and awarded as appropriate.

8. Amount of money claimed is $ 
 
 
9. The reasons for the claim are: 
 

 .

 .

 .

 .

 .

City, state, zip                                                                 Telephone no.

Day

See additional notice and instructions on page 2.
1. 

NOTICE OF HEARING
For Court Use Only

Plaintiff

Address

2. 

Defendant

Address

 

 

 

 
 

 

 

 

 

 

 

 

 

 

10.  The plaintiff understands and accepts that the claim is limited to $6,500 by law and that the plaintiff gives up the rights to
 

  (a) recover more than this limit, (b) an attorney, (c) a jury trial, and (d) appeal the judge’s decision.

Approved, SCAOForm DC 84, Rev. 3/23MCL 600.8401 et seq., MCR 4.302, MCR 4.303, 50 USC 3931Page 1 of 2Distribute form to: Court (with instructions)Defendant (with instructions)Plaintiff (with instructions)Return (with proof of service)STATE OF MICHIGANJUDICIAL DISTRICTAFFIDAVIT AND CLAIMSmall ClaimsCASE NO. and JUDGECourt address                     Court telephone no.     Affidavit and Claim, Small Claims 
Page 2 of 2

(3/23) 

11.  I believe the defendant 
 

  older.

 is 

 is not  mentally competent. I believe the defendant 

 is 

 is not  18 years or 

Case No. 
 

  I do not know whether the defendant is in the military service. 
  The defendant is in the military service. 

  The defendant is not in the military service.
 

 

 

 

12. 
  
 
                     
 

 
 

 

 
 

 

Signature

 

 

 

 

 

 

Subscribed and sworn to before me on 
 
 

                     
                     

Date

My commission expires on 
 
Notary public, State of Michigan, County of 

                     

 

 

Deputy clerk/Notary public signature

 . 

Name (type or print)
 

 

 . 

 Acting in the County of 

 

 This notarial act was performed using an electronic notarization system or a remote electronic notarization platform.

 . 
 

 .

TO BOTH THE PLAINTIFF AND THE DEFENDANT:

ADDITIONAL NOTICE AND INSTRUCTIONS

•  You must bring to the hearing all witnesses, books, papers, and other physical evidence needed to prove or disprove this 
 

claim.

•  Before the trial (hearing) starts, you have the right to

1. remove the case to the general civil division of the district court, or

2. have the case heard by a district court judge (if the hearing is scheduled before an attorney magistrate).  If the case 
    is heard by an attorney magistrate, you may appeal to the district judge within 7 days after the trial.

• 
 

If the case is tried in the small claims division, you give up the right to an attorney, to a jury trial, and to appeal the judge’s
decision.

If you require accommodations to use the court because of a disability or if you require a foreign language interpreter to help 
you fully participate in court proceedings, please contact the court immediately to make arrangements.

TO THE DEFENDANT:

•  The affidavit and claim you have just received means you are being sued in the small claims division of the district court.

•  The court is being asked to decide a matter that the plaintiff says is your obligation and responsibility.

If you wish to deny this claim or arrange terms of payment, you must make your request by appearing at the date, time, 
and place stated in the notice of hearing on the front of this form.

If you do not appear at the date, time, and place stated, a default judgment may be entered against you for the amount 
stated in item 8, including the costs of this action.

• 

If the dispute is settled before or at the hearing, you may have to pay the plaintiff’s costs.

• 
 

In case a judgment is entered against you at the hearing, you should be prepared to pay the amount stated in item 8,
including the costs of this action, or to make arrangements for installment payments. 

 

 
 

• 
 

• 
 

Affidavit and Claim, Small Claims 

(3/23) 

Case No. 
 

PROOF OF SERVICE

TO PROCESS SERVER: You must serve the affidavit and claim no later than 7 days before the hearing date and file 
proof of service with the court clerk. If you are unable to complete service, you must return this original and all copies to 
the court clerk.

CERTIFICATE OF SERVICE / NONSERVICE

 I served 

 

 personally 

 

 by registered or certified mail, return receipt requested, and delivery restricted to the  
  a copy of the affidavit and claim, together with 

  defendant or  the defendant’s agent (copy of return receipt attached)   
 

the attachments listed below, on: 

 I have attempted to serve a copy of the affidavit and claim, together with the attachments listed below, and have been   

  unable to complete service on:

Name

Date and time of service

Place or address of service

Attachments (if any)

 I am a sheriff, deputy sheriff, bailiff, appointed court officer or attorney for a party.

 I am a legally competent adult who is not a party or an officer of a corporate party. I declare under the penalties of 

  perjury that this certificate of service has been examined by me and that its contents are true to the best of my
 

information, knowledge, and belief.

                     

 
Service fee
$

 

                     
Incorrect address fee
$
 

                     

Miles traveled

Miles traveled

Fee
$

Fee
$

 

 

 

 

 

 

TOTAL FEE
$

  
Signature

  
Name (type or print)

  

I acknowledge that I have received service of a copy of the affidavit and claim, together with 

ACKNOWLEDGMENT OF SERVICE

Attachments (if any)    

Signature

Name (type or print)

 on 

Date and time

 on behalf of 
  

 . 

 

MCL 600.8405, MCR 2.105, MCR 4.303