MAGISTRATE COURT OF EFFINGHAM COUNTY 700 N. Pine Street, Suite 250 Springfield, GA 31329 912-754-2124 Case No. Date Filed: PLAINTIFF MAILING ADDRESS DEFENDANT PHYSICAL ADDRESS MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL) CITY, STATE AND ZIP CODE DAYTIME CONTACT NUMBER CITY, STATE AND ZIP CODE DAYTIME CONTACT NUMBER EMAIL ADDRESS STATEMENT OF CLAIM Suit on a Note Suit on Account Other (Explain) Plaintiff says the defendant is indebted to the plaintiff as follows: The said claim is in the amount of $ State of Georgia, Effingham County: plus $ court costs; and all future cost of this suit. being duly sworn on oath, says that foregoing is a just and true statement of the plaintiff and claim made be plaintiff against defendant, exclusive of all set-offs and just grounds of defense and is not, or is unable to further declare under the penalty of perjury that the defendant is, determine a member of the Armed forces of the United States on active duty. This affidavit is executed pursuant to the Soldiers and Sailors Civil Relief Act, 50 USC App a520 as required before any judgment in default may be entered by the court. Any person who shall make an affidavit required under this section, or statement, declaration, verification or certificate certified or declared to be true under penalty of perjury, knowing it to be false, shall be guilty of a misdemeanor and shall be punished by imprisonment not to exceed one year or by fine not to exceed $1,000 or both. Sworn and subscribed before me This day of , 20 . (Agency for) Plaintiff (If agent, Title/ capacity) Notary Public or Attesting Official NOTICE AND SUMMONS TO: ALL DEFENDANTS You are hereby notified that above named plaintiff (s) has/have made and filed a claim and is asking for judgment against you in the sum shown by the foregoing statement. YOU ARE REQUIRED TO FILE OR PRESENT AN ANSWER TO THIS CLAIM WITHIN 30 DAYS AFTER SERVICE OF THIS CLAIM UPON YOU. IF YOU DO NOT ANSWER, JUDGMENT BY DEFAULT WILL BE ENTERED AGAINST YOU. YOUR ANSWER MAY BE FILED IN WRITING OR MAY BE GIVEN ORALLY TO THE CHIEF OR PRESIDING MAGISTRATE DURING REGULAR COURT HOURS. The court will hold a hearing upon this claim at a time to be set after your answer is filed. If you have witnesses, books, receipts, or other writings bearing on this claim, you should bring them with you at the time of hearing. If you wish to have witnesses summoned, see the court at once for assistance. If you have any claim against the plaintiff, you should notify the court at once. If you admit the claim, but desire additional time for pay, you must come to the hearing in person to state the circumstances to the court. You may come with or without an attorney. Magistrate, Effingham County American LegalNet, Inc. www.FormsWorkFlow.com