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District Court Rules
Schedule: C - Forms in civil proceedings Form: 40.02 Claim notice: debt claim not exceeding €15,000
S.I. No. 596 of 2014
40.02
Claim notice: debt claim not exceeding €15,000
Schedule C
O.40, r. 5
District Court Area of
District No.
Record number:
Between
.............. Claimant
............ Respondent
CLAIM NOTICE: DEBT CLAIM
This claim notice is issued at the request of the claimant(s), who makes a claim in the District Court to recover against the respondent damages not exceeding €15,000 for *debt *liquidated damages
Particulars of first claimant:
| Name |  |
| Address | *(in the above Court *(area) and district) |
| *Solicitor | |
| Address for service of documents | |
[Repeat particulars for second and any subsequent claimant]
Particulars of first respondent:
| Name | |
| Address | *(in the above Court *(area) and district) |
| *Solicitor (if known) | |
| Address for service of documents (if known) | |
[Repeat particulars for second and any subsequent respondent]
STATEMENT OF CLAIM
[Set out in numbered paragraphs a statement of all material facts on which the claimant relies, including necessary particulars of such fact, which must include the place where and the date when the claim arose, but not the evidence by which those facts are to be proved. Specify in that statement the specific provisions of any enactment that is relied on and the amount or other relief or remedy sought. An example is provided at the end of this form.]
LIST OF CORRESPONDENCE AND OTHER DOCUMENTS ON WHICH THE CLAIMANT WILL RELY AT TRIAL
| Document | Date | Description |
| 1 | e.g. letter of offer | 1 September 2013 | Letter of offer from the claimant to the respondent |
| 2 | e.g. contract | 10 September 2013 | Contract signed by the claimant and the respondent |
| Etc | | | |
(A) IF YOU DISPUTE THE CLAIM and wish to defend the proceedings, then you must give, or send by post, to the claimant or claimant’s solicitor at the address for service mentioned above an appearance and defence in Form 42.03, Schedule C of the District Court Rules, not later than 28 days after the service on you of this claim notice, and at the same time file a copy of your appearance with the District Court Clerk at the address below.
(B) IF YOU PAY THE AMOUNT of €...... and costs of € ....... to the claimant or the claimant’s solicitor within ten days and without filing and serving an appearance and defence you may avoid further costs.
IF YOU DO NOT ACT IN ACCORDANCE WITH (A) OR (B) ABOVE you will be held to have admitted the claim and the claimant may, without further notice to you, lodge an affidavit of debt in the District Court, obtain judgment and proceed to execution for the full amount claimed and costs.
Signed: ............
*(Solicitor for) Claimant
To the respondent(s) at the address(es) given above
This claim notice is issued at ....... on the ....... day of ....... 20.... by ....... the District Court Clerk assigned to the above Court area and district
*Delete where inapplicable
Sample statement of claim: debt claim
Outstanding invoices
1. The claimant is a wholesale supplier of food and ingredients to the catering industry, and operates his business from 1 Main Street, Dublin 4.
2. The respondent is the operator of a restaurant at 6 New Street, Dublin 4, within the Court area and Court district mentioned above.
3. The claimant has supplied food and ingredients to the respondent since 1997. Since 2012, the respondent’s payments have been erratic and often considerably in arrears.
4. The claimant’s claim is to recover against the respondent the sum of €9,500.00 being the amount due and owing to the claimant by the respondent pursuant to invoices issued in the course of business by the claimant to the respondent on foot of the respondent’s account with the claimant for the supply of food and ingredients.
5. Despite demands made in writing (details of which are set out below), the respondent has failed, refused and/or neglected to pay the amount due and owing to the claimant of €9,500.00, which remains due and owing by the respondent to the claimant after all just credits and allowances.
PARTICULARS OF AMOUNT DUE
| Date of invoice or payment | Amount invoiced € | Amount paid € | Balance due € |
| 1 January 2013 | 4,000.00 | | 4,000.00 |
| 20 January 2013 | | 1,500.00 | 2,500.00 |
| 6 February 2013 | 1,200.00 | | 3,700.00 |
| 26 February 2013 | 2,300.00 | | 6,000.00 |
| 4 March 2013 | | 500.00 | 5,500.00 |
| 9 April 2013 | 3,100.00 | | 8,600.00 |
| 16 May 2013 | 2,400.00 | | 11,000.00 |
| 2 June 2013 | | 1,500.00 | 9,500.00 |
| | | |
| Total due | | | 9,500.00 |
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