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This is an example of a completed statement of claim - debt. It is important to complete this form using your own details and based on your own circumstances. If you need more help, get legal advice. Do not try to file this sample form at court.
This sample form is provided in Word format.
Sample statement of claim - debt (43kb)
For more information on completing this form, see Instructions for filling out a statement of claim - debt.
This sample form is based on the following case study:
Case study – Meena and Fantastic Florists
Meena runs a small business from home, doing website design and IT support for other small businesses. One of her regular clients, Fantastic Florists, has failed to pay her invoice in the amount of $4,000 for the website she built. Meena sent a couple of reminder letters but there has been no response. She tried to contact Fiona from Fantastic Florists by telephone but could not reach her. Meena sent a letter of demand to Fantastic Florists. Fiona from Fantastic Florists offered to pay for part of the outstanding invoice. Meena refused Fiona's offer and has decided to start legal action in the Small Claims Division of the Local Court to recover the outstanding amount from Fantastic Florists.