AFFIDAVIT OF DEBT Comes now affiant, and states: I am (name of Affiant) Plaintiff OR A designated full - time employee of (Plaintiff) (Name of Plaintiff) I am of adult age and am fully authorized by Plaintiff to make the following representations. I am familiar with the record keeping practice of Plaintiff. The following representations are true according to documents kept in the normal course of Plaintiff Plaintiff: Is the original owner of this debt, and evidence of the debt, as required in Rules 2(B)(4)(a) and (b), is attached as one or more Exhibits to this Affidavit. OR has obtained this debt from and the original owner of this debt was . Evidence of the debt, as required in Rule 2(B)(4)(c), is attached as one or more Exhibits to this Affidavit. , Defendant, has unpaid balance of $ on account . (Name of Defendant) ( last 4 digits of number or id only ) That amount is due and owing to Plaintiff. This account 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 required to be attached) Other: (Please explai n) This account balance includes: Late fees in the amount of $ as of . (Month, Day, Year) Other (Explain ). Interest at a rate of % beginning . (Month, Day, Year) Plaintiff: additional evidence will be presented to the court prior to OR American LegalNet, Inc. www.FormsWorkFlow.com Plaintiff believes that defendant is not a minor or an incompetent individual. If the defendant is an individual, plaintiff states and declares that: on active military service is based upon the following facts: . OR Plaintiff is unable to determine whether or not Defendant is not on active military service military service. military (including the National Guard and reserves) and, for members of the National Guard, service under a call to active service authorized by the President or Secretar the Servicemembers Civil Relief Act, as amended, 50 U.S.C.A. Appx. 247 521.) I swear or afform under the penalties of perjury that the foregoing representations are true. Da te: Signature of Affiant: American LegalNet, Inc. www.FormsWorkFlow.com