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) ) SS: COUNTY OF HAMILTON ) STATE OF INDIANA IN THE SUPERIOR COURT NO. 5 OF HAMILTON COUNTY _____________________________________ Plaintiff v. _____________________________________ Defendant CAUSE NO. 29D05-_______________________ AFFIDAVIT OF DEBT (for a claim on account) Comes now affiant, and states: I, ____________________________________________ (name of affiant) am the Plaintiff or a designated full-time employee of the Plaintiff. I am of adult age and am fully authorized by Plaintiff to make the following representations. I am familiar with the record keeping practices of Plaintiff. The following representations are true according to documents kept in the normal course of Plaintiff's business and/or my personal knowledge: Plaintiff: is the original owner of this debt. or has obtained this debt from __________________________ and the original owner of this debt was _____________________________________. _______________________________, Defendant, has an unpaid balance of $___________ on account __________ (last 4 digits of number or I.D. only). That amount is due and owing to Plaintiff. This account was opened on ________________. The last payment from Defendant was received on ________________ in the amount of $________________. The type of account is: Credit card account (i.e., Visa, MasterCard, department store, etc.) List the name of the company/store issuing credit card: ____________________________________ Account for utilities (i.e., telephone, electric, sewer, etc.) (over) American LegalNet, Inc. www.FormsWorkFlow.com Medical bill account (i.e., doctor, dentist, hospital, etc.) Account for services (i.e., attorney fees, mechanic fees, etc.) Judgment issued by a court (a copy of the judgment is required to be attached) Other (please explain): _________________________________________________ __________________________________________________________________ This account balance includes: Late fees in the amount of $____________ as of ___________________________ (month, day, year) Other (explain): ______________________________________________________ Interest at a rate of ____% beginning on _________________________________ (month, day, year) Plaintiff: is seeking attorney's fees and additional evidence will be presented to the Court prior to entry of judgment on attorney's fees. or is not seeking attorney's fees. Plaintiff believes that the Defendant is not a minor or incompetent individual. If Defendant is an individual, Plaintiff states and declares that: Defendant is not on active military service. Plaintiff's statement that Defendant is not on active military service is based upon the following facts: ________________ __________________________________________________________________ or Plaintiff is unable to determine whether or not Defendant is not on active military service. ("Active military service" includes full time duty in the military [including the National Guard and reserves] and, for members of the National Guard, service under a call to active service authorized by the President or Secretary of Defense. For further information, see the definition of "military service" in the Servicemembers Civil Relief Act, as amended, 50 U.S.C.A Appx. § 521.) I swear or affirm under the penalties of perjury that the foregoing representations are true. Date: _________________________ ___________________________________ Signature of affiant American LegalNet, Inc. www.FormsWorkFlow.com Rev. 3/11 Aff.of.Debt