Ind. R. Small. Claims. Ct. A
Comes now affiant, and states: I__(Name of Affiant)__ am
[ ] Plaintiff
OR
[ ] a designated full-time employee of ____(Name of Plaintiff)___ Plaintiff.
I am of adult age and am fully authorized by Plaintiff to make the following representations. I am familiar with the recordkeeping 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, and evidence of the debt, as required in Rules 2(B)(4)(a) and (b), is attached as one or more Exhibits to this Affidavit.
OR
[ ] has obtained this debt from __________________________and the original owner of this debt was ________________________________________. Evidence of the debt, as required in Rule 2(B)(4)(c), is attached as one or more Exhibits to this Affidavit.
__(Name of Defendant)__,Defendant, has an unpaid balance of $________on account _(last 4 digits of number or id 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.)
[ ] 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 defendant is not a minor or an incompetent individual.
If the 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 military service.
("Active military service" includes fulltime 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.
Dated: ______________
Signature of Affiant:_______________________________________
Ind. R. Small. Claims. Ct. A