Affidavit of Debt

Comes now affiant, and states:

(Name of Affiant)

Plaintiff

a designated full-time employee of

(Name of Plaintiff)

(Plaintiff).

I am of adult age an 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.

has obtained this debt from and the original owner of

this debt was .

(Name of Defendant)

, Defendant, has unpaid balance of $ on account

(last 4 digits of acct. number or id only)

That amount is due and owing to Plaintiff. This account was opened on . 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 require to be attached)

Other: (Please explain)

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.