(Revised 7/05) File Stamp Date Case Number ______ Prepared by: Filer's name, SC# Filer's address Filer's phone number {Filer's fax phone number} {Filer's e-mail address} Attorney for Plaintiff In The District Court of ______ County, Kansas Plaintiff's name vs. Defendant's name Defendant's address Pursuant to Chapter 61 of Kansas Statutes Annotated Service By: Certified Mail PETITION (worthless check) The plaintiff states the following claim(s): 1. That the defendant(s) gave one or more worthless checks as defined by law. 2. That plaintiff is the holder of said check(s) and has made proper written demand upon defendant for payment as required by law pursuant to K.S.A. 60-2610. More than fourteen (14) days have passed thereafter without payment by the defendant(s). 3. That pursuant to K.S.A. 60-2610, plaintiff is entitled to judgment against the defendant(s) for the amount of the check(s) in the amount of $______, interest before judgment in the amount of $______, the incurred service charge in the amount of $______, the costs of restricted mail in the amount of $______, statutory damages in the amount of $______, and reasonable attorney fees in the amount of $______ and any additional attorney fees ordered by the court. 4. That defendant(s) may, prior to the commencement of a dispositional hearing by the Court, tender to plaintiff as satisfaction of the claim an amount of money equal to $______ Defendant Plaintiff Case No. ______ American LegalNet, Inc. www.USCourtForms.com which amount is equal to the sum of the amount of the check(s), the incurred court costs, service charge, costs of restricted mail and the costs of collection, including but not limited to reasonable attorney fees. WHEREFORE, plaintiff demands judgment against the defendant(s) for: Face amount of check(s) Service charge Restricted mail costs Statutory damages Attorney fees Interest before judgment for a total of plus interest after judgment and court costs. $ ______, $ ______, $ ______, $ ______, $ ______, $ ______, $ ______, ______ % per year, _________________________________ Plaintiff or Plaintiff Attorney Signature SC# {If applicable, include the following: This is a communication from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose.} American LegalNet, Inc. www.USCourtForms.com