Statement of Claim.

THE UNITED REPUBLIC OF TANZANIA

JUDICIARY

IN THE COURT OF RESIDENT MAGISTRATE/DISTRICT COURT

OF .....................AT.................

SMALL CLAIM CASE NO............OF................

...................................................... CLAIMANT(S)

VERSUS

.....................................................RESPONDENT(S)

STATEMENT OF CLAIM

(Made under rule 5(1), 8(2), 10(1) and 11(2 of the Magistrates’ Courts (Small Claims Procedure) Rules, 2022)

1. Name in full

.Johnson Yesaya Mgelwa ...........................................................Claimant

Legal status of the claimant (tick whichever is appropriate)

□ Natural person □ sole proprietorship □ partnership □ company □ co- operative society □ Government □ others (specify)..........................................................................................................................................

Residential address - House No. 23 Cocacola Road Mikocheni.

Business and postal address PSSSF Tower. 5th Floor, Sam Nujoma Road.

Post code - 11002

Phone number - 07_________________

Email address...........................................................................................

and

2. Name in full

.....................................................................................................Respondent

Legal status of the respondent (tick whichever is appropriate)

□ Natural person □ sole Proprietorship □ partnership □ company □ co- operative society □ Government □ others (specify)...................................................................

Residential address.....................................................................................

Business and postal address PSSSF Tower. 5th Floor, Sam Nujoma Road.

Post code................................................................................................

Phone number..........................................................................................

Business and postal address..........................................................................

Email address............................................................................................

In case of multiple claimants or respondents, give the details of each claimant or respondent.

3. Nature of the claim and cause of action (tick whichever is appropriate)

□ Recovery of civil debts

□ Interests due to the Government under any judgment and written law

□ Recovery of any civil debt arising out of contract

□ Any other cause of action (briefly specify)

......................................................... ...........................................................................................................

4. Date of cause of action:............................................................................................................................

5. Briefly explain the circumstances under which the claim arose and attach documents in support of your claim (if any).

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6. Reliefs sought; (tick whichever is appropriate)

□ Judgement in the sum of Tshs ..................................

□ Compensation

□ Costs of the claim (to be assessed by the court)

□ Other appropriate reliefs (briefly explain)

.....................................................................................................................................................................

7. Fill this part if the amount claimed exceeds the amount of the small claim.

By filing this claim, I .................................................... (the claimant) hereby abandon and forfeit the recovery of all sums in excess of Tshs ..............................................., excluding costs and interest.

...........................

signature of claimant

VERIFICATION

I verify that the information given above is true to the best of my knowledge.

..................................

signature of the claimant

Verified at Dar-es-salaam this ................. day...........................of 2024

..................................

signature of the claimant

Presented for filing this.......................day of.............................of 2024

signed ..................................

registry officer