On June 04, 2024 a
Party Statement
was filed
involving a dispute between
Northern Star Cooperative,
and
Burchill, Sam,
for Conciliation
in the District Court of Itasca County.
Preview
JUN 0 ll 202k
'led in District
Court
F'State of Minnesota
State of Minnesota Conciliation Court
County of: Judicial District: Ninth
Itasca Court File Number:3'("CO ~Zt-i'flZZ
Case Type: ConcMafion
STATEMENT OF CLAIM AND SUMMONS
Plaintiff #1 Plaintiff #2
Name: Northern Star Cooperative Name:
Address: 105 Main Ave W Address:
PO BOX 458
City/Stam/Zip Deer River, MN 56636 Eity/State/ Zip:
Defendant #1 Defendant #2
Naxmz: SAM BURCHILL Name:
Address: 5896 PARKWOOD COURT Address:
City/State/Zip: BAXTER, MN 56425 City 'State/Zip
D Check box ifthere are more than two plaintiffs or more than two defendants. List the
information for the other parties on the Addili()nal Litiganl.v Form, CCT702.
PLAINTIFF'S STATEMENT OF CLAIM
l. I am filing this claim against Defendant for: (check all that apply?
EThe Defendant owes me $ 1,094.31 , plus filing fees and costs in the amount of
$ 75.00 , so my total claim is for $ 1,169.31 (amount Defendant owes
plus filing fees and costs). I have a claim for this amount because in
see below (month and year), the following happened (briefly' describe):
Defendant received LP home heating from Northern Star Cooperative at the address of:
36800 cord 129, Deer River, MN on 4/5/23 and 1/29/24. There has been no payments
received. Ali billing statements, past due, collection and legal notices were sent to
address listed above for Defendant. The Defendant called on 1/25/24 with new address
listed on this claim. No notices were sent back to us and there has been no other contact
made from the Defendant. Exhibits A & B are attached.
D The Defendant has the followingc P ro P ertx' that belongs to me (list pro P ertv):
a .
CCT102 State ENG Rev 1/20 www.mncourtsgov/forms Page 1 of3
My property is valued at $ . The filing fees and costs for this case are
$ . I want the court to order this property returned to me or make the
Defendant pay me 3; (property's value plus the filing fees and costs).
2. I believe the person I am suing is at least 18 years old.
Defendant #1 date of birth: / El Unknown.
Defendant #2 date of birth: / D Unknown.
[fa defendant is a business, leave this section blankfor that defendant.
3. About military service:
Defendant #l is [j in the military service / [:J is not in the military service D Unknown.
Defendant #2 is [j in the military service/ [:1 is not in the military service [3 Unknown.
If a defendant is a business, leave this section blank for that defendant.
4. I understand that ifl do not come to court on
my hearing date, my case may be dismissed
and may have to pay money to the Defendant on any counterclaim that has been filed.
1
Ideclare under penalty of perjury that everything that l have stated in this document is true and
correct. Minn. Stat. § 358.l 16.
Important! Each plaintiff must Sign the Statement ofC/aim and Summons form and include
the date signed, the name of the state and county where signed, and provide the following
information: title, ifany, telephone number, and e-ma' addrx
'\\
Dated; 05/30/2024
--
(V &;2\ \V .N\Q\V\
Signature
Itasca County, MN Naine: Brenda Hendrickson, Cr. Mgr.
County and State where signed
Address; 105 Main Ave W., PO Box 458
City/State/Zip: Deer River, MN 56636
Telephone: 218-246-8296 X107
b.hendrickson@northernstarc00p.co
E-mail address: m
CCT102 State ENG Rev 1/20 www.mncourts.gov/f0rms Page 2 of 3
SUMMONS: IMPORTANT NOTICE T0 THE PARTIES
You are summoned t0 appear at the hearing ofthe above-entitled case. See the attached Notice
of Hearing for time and location. lfnot attached, call Conciliation Court in
County.
If the defendant does not appear at the hearing, the plaintiff may Win this case by default,
which means the plaintiff could be awarded a money judgment against the defendant.
The judgment could include the amount the plaintiff requested in the Statement of Claim
as well as other fees and costs approved by a judicial officer.
If the plaintiff does
not appear at the hearing, this case may be dismissed. If the
defendant has filed a counterclaim, then a default judgment could be entered against the
plaintiff.
The Defendant may bring a counterclaim against the Plaintiff. A counterclaim must be filed at
least 7 days before the Conciliation Court hearing. For forms, instructions, and more
information, see Information About Conciliation Court (court form CCTlOl) on the court's
website starting at www.mncourtsgov/forms.
NOTICE OF SETTLEMENT
The above-entitled case has been settled, and is dismissed with my consent.
Important! Each plaintiff who has settled the case must sign and date this "Notice of
Settlement" section.
Dated:
Signature
CCT102 State ENG Rev 1/20 wwwmncourtsgov/forms Page 3 of3
6dr
Worfllern Star
Cooperative Services
On this :2 094K day of /\'\O"k\ f 2024,, I
hereby authorize Brenda Hendrickson
to represent the interest of Northern Star Cooperative Services in matters regarding and
pertaining to the colleCtion of Accounts Receivabl'e and/0r Real Property owned by the
cooperative.
V
fia'dlley J. Box, '7
/
Chief Executive Officer
Northe,rn Star Cooperative Services
Document Filed Date
June 04, 2024
Case Filing Date
June 04, 2024
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
JUN 0 ll 202k 'led in District Court F'State of Minnesota State of Minnesota Conciliation Court County of: Judicial District: Ninth Itasca Court File Number:3'("CO ~Zt-i'flZZ Case Type: ConcMafion STATEMENT OF CLAIM AND SUMMONS Plaintiff #1 Plaintiff #2 Name: Northern Star Cooperative Name: Address: 105 Main Ave W Address: PO BOX 458 City/Stam/Zip Deer River, MN 56636 Eity/State/ Zip: Defendant #1 Defendant #2 Naxmz: SAM BURCHILL Name: Address: 5896 PARKWOOD COURT Address: City/State/Zip: BAXTER, MN 56425 City 'State/Zip D Check box ifthere are more than two plaintiffs or more than two defendants. List the information for the other parties on the Addili()nal Litiganl.v Form, CCT702. PLAINTIFF'S STATEMENT OF CLAIM l. I am filing this claim against Defendant for: (check all that apply? EThe Defendant owes me $ 1,094.31 , plus filing fees and costs in the amount of $ 75.00 , so my total claim is for $ 1,169.31 (amount Defendant owes plus filing fees and costs). I have a claim for this amount because in see below (month and year), the following happened (briefly' describe): Defendant received LP home heating from Northern Star Cooperative at the address of: 36800 cord 129, Deer River, MN on 4/5/23 and 1/29/24. There has been no payments received. Ali billing statements, past due, collection and legal notices were sent to address listed above for Defendant. The Defendant called on 1/25/24 with new address listed on this claim. No notices were sent back to us and there has been no other contact made from the Defendant. Exhibits A & B are attached. D The Defendant has the followingc P ro P ertx' that belongs to me (list pro P ertv): a . CCT102 State ENG Rev 1/20 www.mncourtsgov/forms Page 1 of3 My property is valued at $ . The filing fees and costs for this case are $ . I want the court to order this property returned to me or make the Defendant pay me 3; (property's value plus the filing fees and costs). 2. I believe the person I am suing is at least 18 years old. Defendant #1 date of birth: / El Unknown. Defendant #2 date of birth: / D Unknown. [fa defendant is a business, leave this section blankfor that defendant. 3. About military service: Defendant #l is [j in the military service / [:J is not in the military service D Unknown. Defendant #2 is [j in the military service/ [:1 is not in the military service [3 Unknown. If a defendant is a business, leave this section blank for that defendant. 4. I understand that ifl do not come to court on my hearing date, my case may be dismissed and may have to pay money to the Defendant on any counterclaim that has been filed. 1 Ideclare under penalty of perjury that everything that l have stated in this document is true and correct. Minn. Stat. § 358.l 16. Important! Each plaintiff must Sign the Statement ofC/aim and Summons form and include the date signed, the name of the state and county where signed, and provide the following information: title, ifany, telephone number, and e-ma' addrx '\\ Dated; 05/30/2024 -- (V &;2\ \V .N\Q\V\ Signature Itasca County, MN Naine: Brenda Hendrickson, Cr. Mgr. County and State where signed Address; 105 Main Ave W., PO Box 458 City/State/Zip: Deer River, MN 56636 Telephone: 218-246-8296 X107 b.hendrickson@northernstarc00p.co E-mail address: m CCT102 State ENG Rev 1/20 www.mncourts.gov/f0rms Page 2 of 3 SUMMONS: IMPORTANT NOTICE T0 THE PARTIES You are summoned t0 appear at the hearing ofthe above-entitled case. See the attached Notice of Hearing for time and location. lfnot attached, call Conciliation Court in County. If the defendant does not appear at the hearing, the plaintiff may Win this case by default, which means the plaintiff could be awarded a money judgment against the defendant. The judgment could include the amount the plaintiff requested in the Statement of Claim as well as other fees and costs approved by a judicial officer. If the plaintiff does not appear at the hearing, this case may be dismissed. If the defendant has filed a counterclaim, then a default judgment could be entered against the plaintiff. The Defendant may bring a counterclaim against the Plaintiff. A counterclaim must be filed at least 7 days before the Conciliation Court hearing. For forms, instructions, and more information, see Information About Conciliation Court (court form CCTlOl) on the court's website starting at www.mncourtsgov/forms. NOTICE OF SETTLEMENT The above-entitled case has been settled, and is dismissed with my consent. Important! Each plaintiff who has settled the case must sign and date this "Notice of Settlement" section. Dated: Signature CCT102 State ENG Rev 1/20 wwwmncourtsgov/forms Page 3 of3 6dr Worfllern Star Cooperative Services On this :2 094K day of /\'\O"k\ f 2024,, I hereby authorize Brenda Hendrickson to represent the interest of Northern Star Cooperative Services in matters regarding and pertaining to the colleCtion of Accounts Receivabl'e and/0r Real Property owned by the cooperative. V fia'dlley J. Box, '7 / Chief Executive Officer Northe,rn Star Cooperative Services