INTERPLEADER ACTION DOCKET NUMBER STATE OF TENNESSEE, COUNTY OF KNOX To Any Lawful Office to Execute and Return: Summon Defendants, Buyer whose address is REALTY COMPANY/PLAINTIFF and Seller VS whose address is to appear before the Court of General Sessions of Knox County, Tennessee, to be held at the 5th Sessions Courtroom of said BUYER/DEFENDANT court in said county on the day of , 20, at 9:00 a.m. Old Courthouse, 5th Sessions Court, 300 Main Street, Room 331 Knoxville TN 37902 and there to answer in a civil action, in the nature of an Interpleader, pursuant to 1987 Tennessee Public Acts Section 331, by ADDRESS Plaintiff, whose address is WHEREBY, PLAINTIFF REQUESTS resolution of a dispute over certain money held by Plaintiff in the amount of SELLER/DEFENDANT dollars ($) between Defendants, each of whom claims certain rights therein, and Plaintiff hereby deposits said money into Court. The amount in dispute is less than $25,000.00. ADDRESS PLAINTIFF FURTHER REQUESTS that the Court discharge Plaintiff from all liability with regard to said money INTERPLEADER WARRANT hereby deposited into the Court. Court of General Sessions CHARLES D. SUSANO III JUDGMENT ByDeputy Clerk Judgment for Buyer/ Seller: Issued, 20 Set for at 9:00 a.m. Reset for for $ Dollars. This the day of , 20 Default buyer Served upon: All Named Defendants Default seller All Defendants Except: Judge of Division of the Court of General Sessions Interlocutory orders (if any) Costs to be paid out of Earnest money Served , 20 Served by: Sheriff/Constable (Process Server) Attorney for Buyer: Judge of Division of the Court of General Sessions Telephone: Attorney for Seller: from which judgment the prayed an appeal to the Circuit Court, which is Telephone: granted upon Attorney for Realty Company: This the day of , 20 Telephone: Judge of Division of the Court of General Sessions American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO THE DEFENDANT(S): Tennessee law provides a ten thousand dollar ($10,000.00) personal property exemption from execution or seizure to satisfy a judgment. If a judgment should be entered against you in this action and you wish to claim property as exempt, you must file a written list, under oath, of the items you wish to claim as exempt with the clerk of the court. The list may be filed at any time and may be changed by you thereafter as necessary; however, unless it is filed before the judgment becomes final , it will not be effective as to any execution or garnishment issued prior to the filing of the list. Certain items are automatically exempt by law and do not need to be listed; these include items of necessary wearing apparel (clothing) for yourself and your family and trunks or other receptacles necessary to contain such apparel, family portraits, the family Bible, and school books. Should any of these items be seized, you would have the right to recover them. If you do no understand Your exemption right or how to exercise it, you may wish to seek the counsel of a lawyer. AFFIDAVIT To the best of my information and belief, after investigation of Defendant222s employment, I hereby make affidavit that the Defendant is/is not a member of a military service. ATTORNEY FOR PLAINTIFF OR PLAINTIFF SWORN TO AND SUBSCRIBED BEFORE ME This day of , 20. Notary Public. My term expires: **NOTICE** The American with Disabilities Act prohibits discrimination against any qualified individual with a disability. The Tennessee Judicial Branch does not permit discrimination against any individual on the basis of physical or mental disability in accessing its judicial programs. In accordance with the Americans with Disabilities Act, if necessary, the Tennessee Judicial Branch will provide reasonable modifications in order to access all of its programs, services and activities to qualified individuals with disabilities. If you need assistance, have questions or need additional information, please contact the Local Judicial Program ADA Coordinator: Knox County Human Resources Office Suite 360 City-County Building 400 Main Street, Knoxville, Tennessee 37902 Voice Phone:865-215-2952 TTY:865-215-2497 The Tennessee Judicial Branch Americans with Disabilities Act Regarding Access to Judicial Programs, as Well as a Request for Modification form may be found online at www.tsc.state.tn.us. APPEAL From the judgment on the reverse hereof, the prayed an appeal. To the Circuit Court which is granted upon Pauper222s Oath or Appeal Bond. This day of , 20. Judge of the Court of General Sessions Division No If you require a modification to access the judicial program and/or have special needs because of a qualified disability, you must submit a written Request for Modification to the Local Judicial Program ADA Coordinator listed below at least five (5) business days prior to the date of the judicial program, if possible. A form is available from the Local Judicial Program ADA Coordinator or from the Tennessee Judicial Program ADA Coordinator. http://www.tsc.state.tn.us If you need assistance, have questions or need additional information, you may also contact the Tennessee Judicial Program ADA Coordinator: Pamela Taylor, Manager/Coordinator STATE Judicial ADA Program Administrative Office of the Courts Nashville City Center, Suite 600, 511 Union Street Nashville, Tennessee 37219 615-741-2687 Fax: 615-741-6285 American LegalNet, Inc. www.FormsWorkFlow.com