MAGISTRATE COURT OF COUNTY, GEORGIA DATE FILED CASE NO. STATEMENT OF CLAIM vs. CERTIFICATE OF SERVICE TO OPPOSING PARTY I hereby certify that I [ ] have mailed; [ ] will mail immediately upon filing; a copy of the following listed documents that I have filed with the clerk of court. [ ] Amended Statement of Claim; [ ] Amended Answer/Counterclaim; [ ] Other, ; to Opposing Party: Name, Address This day of , 20. [ ] Plaintiff [ ] Defendant Mailing address City, State & Zip Phone # (Dayime) American LegalNet, Inc. www.FormsWorkFlow.com