22nd Judicial District Court Parish Of Washington Small Claim Suit Page 3

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Please serve defendant
Name ________________________________________
Address_______________________________________
_____________________________________________
Parish of Washington
State of Louisiana
Before me, the undersigned authority personally came and appeared plaintiff, who stated that all allegations
contained in the foregoing petition are true and correct to the best of his/her information and knowledge.
_________________________________
Plaintiff
Sworn and subscribed before me this ______ day of 20_____________________________

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