AFFIDAVIT OF DEBT Comes now affiant, and states: I__________________ am □ Plaintiff (Name of Affiant) 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 practices of Plaintiff. The following representations are true according to documents kept in the normal course of Plaintiff’s business and/or my personal knowledge: Plaintiff: □ is the original owner of this debt. OR □ has obtained this debt from __________________________and the original owner of this debt was ________________________________________. ___________, Defendant, has an 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 was 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 explain)___________________________________________________ ____________________________________________________________________ ____________________________________________________________________. This account balance includes: □ Late fees in the amount of $__________ as of ________________. (Month, Day, Year) □ Other (Explain__________________________________________________) □ Interest at a rate of _____% beginning on _________________. (Month, Day, Year) Plaintiff: □ is seeking attorney’s fees and additional evidence will be presented to the court prior to entry of judgment on attorney’s fees. OR □ is not seeking attorney’s fees. Plaintiff believes that defendant is not a minor or an incompetent individual. TCM-TR9.2-1 Approved by Division of State Court Administration, Feb. 2011 American LegalNet, Inc. www.FormsWorkFlow.com If the defendant is an individual, plaintiff states and declares that: □ Defendant is not on active military service. Plaintiff’s statement that Defendant is not 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. (“Active military service” includes fulltime duty in the 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 Secretary of Defense. For further information, see the definition of “military service” in the Servicemembers Civil Relief Act, as amended, 50 U.S.C.A. Appx. § 521.) I swear or affirm under the penalties of perjury that the foregoing representations are true. Dated: _____________________ Signature of Affiant:_______________________________________ TCM-TR9.2-1 Approved by Division of State Court Administration, Feb. 2011 American LegalNet, Inc. www.FormsWorkFlow.com