MAGISTRATE COURT OF FULTON COUNTY DO NOT WRITE IN THIS SPACE 185 Central Ave., S. W., Suite TG700, Atlanta, GA 30303 Plaintiff: Name, Street Address, City/State, Zip Code Telephone Number: ( ) versus Defendant : Name, Street Address, City/State, Zip Code Plaintiff s Attorney : Name/Address/Zip Code/Phone No. STATEMENT OF CLAIM Type of Suit: O Account 0 Contract O Note 0 Tort 0 Trover 1 . Defendant named resides in Fulton County and is subject to the jurisdiction of this Court. 2. Defendant is indebted to Plaintiff in the sums of $ , principal, $ attorney fees and $ costs to date as follows: (State your claim here) 0 Personal Injury , interest, 3 . WHEREFORE, Plaintiff demands judgment against Defendant in the amounts as alleged in paragraph 2 herein. STATE OF GEORGIA, FULTON COUNTY: After being duly sworn on oath, says the foregoing is a just and true statement ofthe amounts owing by Defendant to Plaintiff; exclusive ofall setoffs and just grounds ofdefense . Sworn to and subscribed before me, this Plaintiff's Signature Deputy Clerk or Notary Public SUMMONS TO THE ABOVE-NAMED DEFENDANT : You are hereby required to file with the Clerkof said Court andto serve a copyonPlaintiff or Plaintiff's Attorney, an answer to the complaint which is herewith served on you, within thirty (30) days after service on you, exclusive ofthe day of service . If you fail to do so, judgment by default will be taken against you for the relief demanded in the complaint, plus cost ofthis action. Your answer may be filed in writing or may be given orally (in person) to the Court . Ifyou mail in your answer it must be notarized . Upon receipt of your answer a hearing date will be set and you will be notified by mail. At said hearing, bring your witnesses, books, receipts or other writings bearing on your claim or defense . Failure to appear at the time of hearing my result in judgment being entered against you. SERVED: Deputy Marshal Deputy Clerk You mayfile an answer at one ofthese locations : 185 Central Avenue, S. W., Room TG700 North Annex : 7741 Roswell Road, Room 231 South Annex : 5600 Stonewall-Tell Road, Room 213 American LegalNet, Inc. www.USCourtForms.com 1a-158-1199