New York Codes, Rules and Regulations
Title 22 - JUDICIARY
Subtitle D - Forms
Chapter IX - Forms For Commercial Claims Parts Of Court
Form UCS-119 - Application to file claim
UCS-119 (Rev. 11/90)
State of New York FOR CLERK'S USE ONLY
________ Court of ________ Notice was mailed on
____________ day of ____________, 19________,
to ____________
(Address of Defendant)
Date of delivery ____________
Home address of person who signed receipt ____________
(from the receipt form)
Application: Small Claim ________
Commercial Claim ________
Commercial Claim ________
(Consumer Transaction)
Filing Fee:
Small Claim - $ 3.00 + postage
Commercial Claim - $20.00 + postage
Dated ________
Name of Claimant ________
Address (if commercial claim, give Principal Office Address)
____________
Telephone ________
-against-
Name if Defendant ________
Address (Home or Bus./Place of Employment) ____________
____________
............ COMPLETE THIS SECTION FOR COMMERCIAL CLAIM ............
[FN1]CERTIFICATION: (NYCCA 1803-A; UCCA 1803-A; UDCA 1803-A)
I hereby certify that no more than five (5) actions or proceedings (including the instant action or proceeding) pursuant to the commercial claims procedure have been initiated in the courts of this State during the present calendar month.
______________
Signature of Claimant
______________
Signature of Notary/Clerk/Judge
UCS-119 (Rev. 11/90)
............ COMPLETE THIS SECTION FOR COMMERCIAL CLAIM ............
ARISING OUT OF A CONSUMER TRANSACTION
[FN1]Certification: (NYCCA 1803-A; UCCA 1803-A; UDCA 1803-A)
I hereby certify that I have mailed a demand letter by ordinary first class mail to the party complained against, no less than ten (10) days and no more than one hundred eighty (180) days before I commenced this claim.
I hereby certify, based upon information and belief, that no more that five (5) actions or proceedings (including the instant action or proceeding) pursuant to the commercial claims procedure have been initiated in the courts of this State during the present calendar month.
______________
Signature of Claimant
______________
Signature of Notary/Clerk/Judge
[FN1] NOTE: The commercial claims part will dismiss any case where this certification is not made.
[FN1] NOTE: The commercial claims part will not allow your action to proceed if this certification is not made and properly completed.
