THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AFFIDAVIT OF DAMAGES AND STATEMENT OF CLAIM AFFIDAVIT OF DAMAGES In accordance with rental payment records of the landlord regarding rental property located at: Street Address City, State, Zip The landlord asserts that the tenant is in arrears in payment of rent in the amount of $ as of . The landlord seeks to recover the arrearage amount plus costs in the amount of $ , associated with filing and service fees. STATEMENT OF CLAIM The landlord/plaintiff claims that the tenant/defendant has failed to make payments on the following due dates: Due Date Amount Due $ $ $ $ Amount Paid $ $ $ $ Date Plaintiff's Signature State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title NHJB-2770-D (08/17/2012) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com