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Superior Court of the District of Columbia CIVIL DIVISION Small Claims and Conciliation Branch 510 4th Street, N.W., Building B, Room 120 Washington, D.C. 20001 Telephone (202) 879-1120 (1) Plaintiff vs. Address (2) (3) Defendant Case No. COUNTERCLAIM DISTRICT OF COLUMBIA, , being first duly sworn, on oath says the foregoing is a just and true statement of the amount owing by the plaintiff to defendant, exclusive of all set-offs and just grounds of defense. Defendant Subscribed and sworn to before me on this date, I hereby accept service Plaintiff Clerk (or notary public) SCCC.doc American LegalNet, Inc. www.FormsWorkFlow.com