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This page links to an example of a completed form. This is the actual form with sample text added in each section.
You should make sure that your form relates to your circumstances. If you need more help to prepare your form, get legal advice.
Do not try to file this sample form.
This sample form is provided in Microsoft Word format.
Sample Statement of claim for goods (39.3KB)
For more information about completing this form, see Instructions for completing a Statement of claim for goods.