STATE OF NORTH CAROLINA

Interest Owed (if any)

Principal Amount Owed

Total Amount Owed

Name And Address Of Defendant 1 Individual Corporation

Name And Address Of Defendant 2

Individual Corporation

Other: (specify)

For conversion (describe property)

(Over)

For a Worthless Check (attach a copy of the check)

On An Account (attach a copy of the account)

For Goods Sold And Delivered Between

For Money Lent

On a Promissory Note

(attach copy)

Interest Rate

STATE OF NORTH CAROLINA

In The General Court Of Justice

District Court Division-Small Claims

County

COMPLAINT

FOR MONEY OWED

G.S. 7A-216, 7A-232

The defendant is a resident of the county named above.

VERSUS

Signature Of Plaintiff Or AttorneyDate

The defendant owes me the amount listed for the following reason:

I demand to recover the total amount listed above, plus interest and reimbursement for court costs.

(check one below)

Ending Date

AOC-CVM-200, Rev. 9/13

Name And Address Of Plaintiff

County

Name And Address Of Plaintiff's Attorney

Telephone No.

Date From Which Interest Due

Beginning Date

Interest Rate

Date From Which Interest Due

ate Of Note

File No.

Name Of Plaintiff Or Attorney (Type Or Print)

The PLAINTIFF must file a small claim action in the county where at least

one of the defendants resides.

The PLAINTIFF cannot sue in small claims court for more than $10,000.00.

This amount may be lower, depending on local judicial order. If the amount

is lower, it may be any amount between $5,000.00 and $10,000.00, as

determined by the chief district court judge of the judicial district.

INSTRUCTIONS TO PLAINTIFF OR DEFENDANT

The PLAINTIFF must show the complete name and address of the

defendant to ensure service on the defendant. If there are two defendants

and they reside at different addresses, the plaintiff must include both

addresses. The plaintiff must determine if the defendant is a corporation

and sue in the complete corporate name. If the business is not a

corporation, the plaintiff must determine the owner's name and sue the

owner.

The P

LAINTIFF may serve the defendant(s) by mailing a copy of the

summons and complaint by registered or certified mail, return receipt

requested, addressed to the party to be served or by paying the costs to

have the sheriff serve the summons and complaint. If certified or

registered mail is used, the plaintiff must prepare and file a sworn

statement with the Clerk of Superior Court proving service by certified

mail and must

attach to that statement the postal receipt showing that the

letter was accepted.

The PLAINTIFF must pay advance court costs at the time of filing this

Complaint. In the event that judgment is entered in favor of the plaintiff,

court costs may be charged against the defendant.

AOC-CVM-200, Rev. 9/13

The DEFENDANT may file a written answer, making defense to the

claim, in the office of the Clerk of Superior Court. This answer

should be accompanied by a copy for the plaintiff and be filed no

later than the time set for trial. The filing of the answer DOES NOT

relieve the defendant of the need to appear before the magistrate to

assert the defendant's defense.

Whether or not an answer is filed, the PLAINTIFF must appear

before the magistrate.

The PLAINTIFF or the DEFENDANT may appeal the magistrate's

decision in this case. To appeal, notice must be given in open court

when the judgment is rendered, or notice may be given in writing to

the Clerk of Superior Court within ten (10) days after the judgment is

rendered. If notice is given in writing, the appealing party must also

serve written notice of appeal on all other parties. The appealing

party must PAY to the Clerk of Superior Court the costs of court for

appeal within twenty (20) days after the judgment is rendered.

This form is supplied in order to expedite the handling of small

claims. It is designed to cover the most common claims.

The Clerk or magistrate cannot advise you about your

case or assist you in completing this form. If you

have any questions, you should consult an attorney.

10.

File No.

Plainti(s)

Date(s) Subsequent Summons(es) Issued

Name And Address Of Defendant 2

Telephone No. Of Defendant 2

Name And Address Of Defendant 1

Telephone No. Of Defendant 1

STATE OF NORTH CAROLINA

County

In The General Court Of Justice

District Court Division - Small Claims

TO TO

(Over)

MAGISTRATE SUMMONS

ALIAS AND PLURIES SUMMONS (ASSESS FEE)

Defendant(s)

Date Original Summons Issued

G.S. 1A-1, Rule 4; 7A-217, -232

VERSUS

Location Of Court

Name And Address Of Plainti Or Plainti’s Attorney

Signature

Date Issued

Deputy CSC

Assistant CSC

Clerk Of Superior Court

Date Of Trial Time Of Trial

AM PM

IMPORTANT! You have been sued! These papers are legal documents, DO NOT throw these papers out!

You may want to talk with a lawyer about your case as soon as possible, and, if needed, speak with

someone who reads English and can translate these papers!

¡IMPORTANTE! ¡Se ha entablado un proceso civil en su contra! Estos papeles son documentos legales.

¡NO TIRE estos papeles!

¡Puede querer consultar con un abogado lo antes posible acerca de su caso y, de ser necesario, hablar

con alguien que lea inglés y que pueda traducir estos documentos!

A Small Claim Action Has Been Commenced Against You!

You are notied to appear before the magistrate at the specied date, time, and location of trial listed below. You will have the opportunity

at the trial to defend yourself against the claim stated in the attached complaint.

You may le a written answer, making defense to the claim, in the oce of the Clerk of Superior Court at any time before the time set for

trial.

If you fail to appear and defend against the proof oered, the magistrate may enter a judgment against you.

AOC-CVM-100, Rev. 12/23

I certify that this summons and a copy of the complaint were received and served as follows:

RETURN OF SERVICE

By delivering to the defendant named above a copy of the summons and complaint.

By leaving a copy of the summons and complaint at the dwelling house or usual place of abode of the defendant named above with a

person of suitable age and discretion then residing therein, who is named below.

As the defendant is a corporation, service was eected by delivering a copy of the summons and complaint to the person named

below.

DEFENDANT 1

Date Served Name Of DefendantTime Served

AM PM

Name And Address Of Person With Whom Copy Left (if corporation, give title of person copy left with)

By delivering to the defendant named above a copy of the summons and complaint.

By leaving a copy of the summons and complaint at the dwelling house or usual place of abode of the defendant named above with a

person of suitable age and discretion then residing therein, who is named below.

As the defendant is a corporation, service was eected by delivering a copy of the summons and complaint to the person named

below.

Name And Address Of Person With Whom Copy Left (if corporation, give title of person copy left with)

Other manner of service

(specify)

Defendant WAS NOT served for the following reason:

DEFENDANT 2

Other manner of service

(specify)

Defendant WAS NOT served for the following reason:

Service was made by mailing by rst class mail a copy of the summons and complaint to the defendant(s) and

by posting a copy of the summons and complaint at the following premises:

Name(s) Of The Defendant(s) Served By Posting

Date Served

Address Of Premises Where Posted

Signature Of Deputy Sheri Making Return

Service Fee

Date Received

Date Of Return

County Of Sheri

Name Of Deputy Sheri Making Return (type or print)

FOR USE IN

SUMMARY

EJECTMENT

CASES ONLY:

Date Served Name Of DefendantTime Served

AM PM

Acceptance of service.

Summons and complaint received by:

Defendant 1.

Other:

Date Accepted Signature

(type or print name)

Acceptance of service.

Summons and complaint received by:

Defendant 2.

Other:

Date Accepted Signature

(type or print name)

AOC-CVM-100, Side Two, Rev. 12/23