IN THE

COURT OF COMMON PLEAS

REPUBLIC OF PALAU

______________________________
)
SMALL CLAIMS
NO. __________
_____________________________, )
Plaintiff(s), )

)
vs. )
SUMMONS ON
COUNTERCLAIM
)

_____________________________, )
Defendant(s), )
______________________________)

TO: ___________________________

ADDRESS: ___________________________

The Defendant(s) has filed a counterclaim against you for $___________ (principal plus pre-
judgment interest, if any, plus court costs, if applicable) for the claims set out in the attached
counterclaim. This matter will be heard in Courtroom _______ at the Judiciary Building in
____________ on the ______ day of ___________________, 20____ at _________ a.m./p.m.
You should bring with you all records and witnesses needed to establish your defense. A default
judgment may be entered against you if you fail to appear. You may make a settlement with
Defendant any time. A small claims ASettlement@ form is available at the Clerk of Courts. You may
also obtain a copy of the ASmall Claims Rules@ from the Clerk of Courts.

Dated: ________________

_________________________________
Clerk of Courts
Republic of Palau
 IN THE
COURT OF COMMON PLEAS
REPUBLIC OF PALAU

______________________________
) SMALL CLAIMS
NO._________
____________________________, )
Plaintiff(s), )
)
vs. )
COUNTERCLAIM
)
)
____________________________, )
Defendant(s), )
______________________________)

Plaintiff(s) owes Defendant(s) $ __________ principal not exceeding three thousand

dollars; $_______ pre-judgment interests, if any; and $_______ court costs, if applicable, for the
following reasons:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
Defendant(s) asks Judgment in the amount of $ (principal balance plus pre-
judgment interest, if any, plus court costs, if applicable) against Plaintiff(s).
I declare under penalty of perjury that the foregoing is true and correct.

Dated: ______________

______________________________
Defendant(s)
 Filed: _______________

______________________________
Clerk of Courts
Republic of Palau

IN THE
COURT OF COMMON PLEAS
REPUBLIC OF PALAU

SMALL CLAIMS NO.

DOCKET STATEMENT

Plaintiff (s): Defendant (s):

Social Securtiy No. Social Security #:

Residential (Home) Address: Residential (Home) Address:

Mailing Address: Mailing Address:

Contact Numbers: Contact Numbers:

(Home): (Home):

(Work): (Mobile): (Work): (Mobile):

Attorney(s): Attorney(s):