In the For File Stamp Only CIRCUIT COURT Of St. Louis County, Missouri _______________________________________ Plaintiff(s),Owner of the leased property _______________________________________ Address _______________________________________ Phone No. vs. _______________________________________ _______________________________________ *Defendant(s) _________________________ Date _________________________ Case Number _______________________ Division ______Post and Serve ______Serve Only ______Post Only Serve at: ___________________________________________________________________ AFFIDAVIT AND STATEMENT IN LANDLORD/TENANT Is the Plaintiff a Corporation or an LLC? _____ Yes _____ No Comes now _______________________________________ Plaintiff(s) or Agent(s) of the above Plaintiff(s) and states under oath that the above Defendant(s) rent and occupies, as tenant(s) or lessee(s) of the Plaintiff, the premises situated in St. Louis County, Missouri, described and known as: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ and said property was rented to the Defendant(s) by the month or under the terms of the lease, payable monthly in advance or on a date set forth in the lease agreement, at the rate of $____________ per month; that the sum of $______________ is now actually due for said rent for the period of ____________________, 201____ to ____________________, 201____; that the same has been demanded from the Defendant(s); and that payment has not been made. Wherefore, Plaintiff(s) pray(s) for Judgment for rent and possession of the above premises with costs. I, the undersigned of lawful age, being duly sworn on my oath, swear that the facts stated in this affidavit are true and correct according to my best knowledge and belief. ________________________________________ Plaintiff Subscribed and sworn to before this _____ day of _______________, 201___. ________________________________________ Notary My Commission expires: _________________________ CCAC163-WS Rev. 02/14 American LegalNet, Inc. www.FormsWorkFlow.com * 3 copies of this document are required for service per defendant.