STATE OF SOUTH CAROLINA COUNTY OF CHARLESTON __________________ __________________ Default: __________________ Hearing: __________________ Case No: __________________ IN THE SMALL CLAIMS COURT ______________________________________ Plaintiff ____________________________________ Defendant Street Address ______________________________________ City State Zip Street Address ____________________________________ City State Zip Served: Filed: Phone Phone I, the plaintiff in this civil action, make the following claim against the defendant: 1.) I believe that the defendant is a resident of _______________________. 2.) Check a, b, or c to indicate the type of suit and supply documents required. a. ( ) This is a suit on a note; Two (2) copies of note attached. Defendant has defaulted in payment of said note with balance of $_______________ now due and payable. b. ( ) This is a suit on an account; Two (2) copies of statement attached. Sign as affiant swearing to statement and have your signature notarized. SWORN and subscribed before me this ___________ day of _______________ 20 ____ ________________________________________ NOTARY PUBLIC, State of South Carolina My Commission Expires:____________________ Attached to this complaint is a statement of account which I swear to be true and correct, with no part of the balance having been paid. ____________________________________ Affiant=s Signature (Plaintiff) c. ( ) OTHER. This is a claim based on the following facts: (Describe Complaint) _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ (attach supplement if necessary) 3.) I believe because of the following information, that I am entitled to, and request a judgment for $__________________ and/or other relief: _________________________________________________________________________________ (Include any costs resulting from this action. (Example: court costs, legal fees, interest) I STATE UNDER PENALTY OF PERJURY THAT THE ABOVE IS CORRECT AND TRUTHFUL. _______________________ Date _______________________________ Signature of Plaintiff or Attorney FORM C32-5270 American LegalNet, Inc. www.FormsWorkFlow.com