AFFIDAVIT OF DEBT

Comes now affiant, and states:

Your Name (Name of Affiant)

am □ Plaintiff

□ a designated full-time employee of

(Name of Plaintiff)

(Plaintiff).

I am of adult age and am fully authorized by Plaintiff to make the following representations. I am familiar with the record keeping practices of Plaintiff. The following representations are true according to documents kept in the normal course of Plaintiff's business and/or my personal knowledge:

Plaintiff:

□ is the original owner of this debt. *-most self-represented use this

□ has obtained this debt from and the original owner of this debt was .

Defendant (Name of Defendant)

, Defendant, has an unpaid balance of $ total due on account

(last 4 digits of number or id only)

That amount is due and owing to Plaintiff. This account was opened on date of service. The last payment from Defendant was received on in the amount of $ .

The type of account is:

□ Credit card account (i.e. Visa, Mastercard, Department Store, etc.)

List the name of the Company/Store issuing credit card:

□ Account for utilities (i.e. telephone, electric, sewer, etc.)

□ Medical bill account (i.e. doctor, dentist, hospital, etc.)

□ Account for services (i.e. attorney fees, mechanic fees, etc.)

□ Judgment issued by a court (a copy of the judgment is required to be attached)

□ Other: (Please explain)

**Choose
One

This account balance includes:

□ Late fees in the amount of $ as of

(Month, Day, Year)

□ Other (Explain)

□ Interest at a rate of % beginning on

(Month, Day, Year)

Plaintiff:

□ is seeking attorney's fees and additional evidence will be presented to the court prior to entry of judgment on attorney's fees.

□ is not seeking attorney's fees. *if not attorney, use this box

Plaintiff believes that defendant is not a minor or an incompetent individual.