VN187 Plaintiff Small Claims Case Number SMALL CLAIMS ITEMIZATION OF DEBT (CCP 116.222) ATTACHMENT TO ITEM 3 OF SC-100 FORM Page _________ NOTE: Use of this form is not mandatory. You may submit this information in any written format (such as a written statement of account) as long as it contains all of the required information. 1. 2. The original debt amount $ __________________ The following payments were credited to the debt: none payments as follows Date payment made continued on attachment Amount of Payment 3. The following fees and charges were added to the debt: none Date added fees and charges as follows continued on attachment Amount of Fees/Charges 4. The following payments were credited against those fees and charges: none payments as follows Date Payment Made continued on attachment Amount of Fees/Charges VN187 Rev 7/07 SMALL CLAIMS ITEMIZATION OF DEBT ATTACHMENT American LegalNet, Inc. www.FormsWorkflow.com VN187 Plaintiff Small Claims Case Number Page _________ 5. All other debits or charges to the account, and an explanation of the nature of those fees, charges, debits are as follows: none other fees, charges and debits as follows: Date added continued on attachment Description of fees, charges and debits 6. All other credits to the debt, including from which source and the amount: none other credits as follows: continued on attachment Source and amount of credits Date of credits to account Other I declare, under penalty of perjury under California State law that the information above is true and correct. Date: ____________ ____________________________ ___________________________ Plaintiff's printed name Plaintiff's signature VN187 Rev 7/07 SMALL CLAIMS ITEMIZATION OF DEBT ATTACHMENT American LegalNet, Inc. www.FormsWorkflow.com