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STATE OF INDIANA ) IN THE SUPERIOR COURT NO. 4 ) SS: COUNTY OF HAMILTON ) OF HAMILTON COUNTY Plaintiff v. CAUSE NO. Defendant 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 Visa, MasterCard, department store, etc.) List the name of the company/store issuing credit card: Account for utilities telephone, electric, sewer, etc.) (over) Clear Form ---PAGE BREAK--- Medical bill account doctor, dentist, hospital, etc.) Account for services 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 Rev. 3/11 Aff.of.Debt