COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA CIVIL DIVISION _______________________________________ Plaintiff/s, CONFESSED JUDGMENT 20 __________ No._______ vs. _______________________________________ Defendant/s. COMPLAINT 1. The parties to this action and their last known addresses are: (a) Plaintiff: (b) Defendant: 2. Paragraphs 3, 6 and 8, below, are printed so as to permit use of alternative statements; and indented words following a block in which an "x" has been inserted are to be read as forming part of this complaint, whereas indented words following a block no so marked are to be considered as deleted. 3. This action is based on an instrument (­ hereinafter referred to as "the Instrument" ­) authorizing confession of judgment, of which ­ ( ) the original ( ) a true and correct reproduction is attached hereto and made a part thereof, marked "Exhibit A." 4. Plaintiff is the owner and holder of the Instrument. * 5. No judgment has been entered on the Instrument in any jurisdiction. ** 6. Judgment may now be entered on the Instrument ( ) because it authorizes confession of judgment unconditionally, without condition precedent and without regard or default. ( ) because of occurrence of the following default/s and/or fullfillment of the following condition/s precedent: * State details of any assignments here. ** State any exceptions here, with identification of proceedings. Words following unmarked blocks may be lined out if desired. American LegalNet, Inc. www.FormsWorkFlow.com 7. The amount now due is as follows: Unpaid balance of principal debt $ Interest at % from to date Attorney's fee as authorized by the Instrument Other charges to the date hereof which are collectible under the Instrument, as follows: ___________________ Total Amount now due $ Interest on the judgment, and all costs and charges collectible under the Instrument, which accrue hereafter are to be collectible under the judgment. 8. Therefore Plaintiff/s demand/s judgment for ­ ( ) The $_____________ penal sum stated in the Instrument, to be satisfied on payment of the amount due, including interest, attorney's fees, costs, and other collectible charges, as of the date of payment. * * ( ) The $_____________ total amount due, as set forth in Paragraph 7, above. LANCASTER COUNTY, ss: _______________________________________ _______________________________________ the above-named plaintiff _____, being duly affirmed according to law, say ______ that the averments in the foregoing Complaint are true, upon the affiant/s * personal * knowledge. * information, and belief ___________________________________________ Notary Public My Commission Expires: ______________________________________________________ Attorney for Plaintiff/s Address: ____________________________________________ ____________________________________________ Plaintiff/s ** This line to be used only if the instrument does not contain a penal sum (i.e., double the original principal amount.) Words following unmarked block may be lined out if desired. Strike out inapplicable words. * American LegalNet, Inc. www.FormsWorkFlow.com