Form 14D

Courts of Justice Act

statement of claim (action commenced by notice of action)

(General heading)

statement of claim

Notice of action issued on (date)

(In an action under the simplified procedure provided in Rule 76, add:)

THIS ACTION IS BROUGHT AGAINST YOU UNDER THE SIMPLIFIED PROCEDURE PROVIDED IN RULE 76 OF THE RULES OF CIVIL PROCEDURE.

1. The plaintiff claims: (State here the precise relief claimed).

(Then set out in separate, consecutively numbered paragraphs each allegation of material fact relied on to substantiate the claim.)

(Where the statement of claim is to be served outside Ontario without a court order, set out the facts and the specific provisions of Rule 17 relied on in support of such service.)

(Date)

(Name, address and telephone number of solicitor or plaintiff)

RCP-E 14D (November 1, 2005)