COMMONWEALTH OF MASSACHUSETTS __________________SS: HOUSING COURT DEPARTMENT _______________________ DIVISION / / /SP-_ / / / / / _____________________________________ Plaintiff/Landlord VS. ______________________________________ Defendant/Tenant AFFIDAVIT UNDER SUMMARY PROCESS RULE 10(d)(ii) I, __________________________________________________, state for an affidavit under penalties of perjury, and from my own personal knowledge, that I am the ___________ ______________________________in this action, th at the defendant -tenant is not an infant or incompetent person, and is not in the military service as defined in the Servicemembers Civil Relief Act, but is instead residing at ____________________________________________ that no payments have been made by or on behalf of the tenant after filing the summary process Complaint, except _____________________, that the tenant owes rent or use and occupancy charges at the rate of $ ______________ per _______________ for the period from ______________________________________________ through __________________________________________as follows: Amount: $ _________________ Date: ____________________ ________________________________________________________________________ ____________ ________________________________________________________________________ ____________ ________________________________________________________________________ ____________ and that there remains due and owing a balance of $ _________________ which balance includes only unpaid rent or use and occupa ncy charges and does not include court costs or other claims, debts, damages or expenses. _______________________________________ Signature and Date: ______________________________________ Name of Plaintiff-Landlord: ________________________________________ Address and Telephone: _______________________________________ American LegalNet, Inc. www.USCourtForms.com