Fillable Affidavit Of Debt Form printable pdf download

STATE OF INDIANA )

IN THE WAYNE SUPERIOR COURT NO. 3

)SS:

COUNTY OF WAYNE )

CAUSE NO. 89D03-____________________________

________________________________________ vs. ________________________________________

Plaintiff(s)

Defendant(s)

AFFIDAVIT OF DEBT

Comes now affiant, and states that I, _______________________________, am Plaintiff or a Designated Full-Time

Employee of 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 the

documents kept in the normal course of Plaintiff’s business and/or my personal knowledge:

Plaintiff is:

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 ________, and the amount is due and owing to Plaintiff.

(last 4 digits only)

This account balance includes:

Late fees in the amount of $_______________ as of ________________

(date)

Interest at the rate of ____% beginning on _________________

(date)

Other ______________________________________________________

This account was opened on __________________.

(date)

The last payment from Defendant was received on __________________ in the amount of $_____________.

(date)

The type of account is:

Credit card account _________________________________________________

(name of bank, company, or store that issued the 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’s fees, mechanic’s fees, etc.)

Judgment issued by a court (attach a copy of the judgment – REQUIRED)

Other ____________________________________________________________

Plaintiff:

is seeking attorney’s fees, and evidence supporting the requested attorney’s fees will be submitted.

is not seeking attorney’s fees.

Plaintiff believes that Defendant is not a minor or an incompetent individual.

If Defendant is an individual, Plaintiff states that:

Defendant is not on active military service, based on a search at: https:// (attach

report) or based on the following facts:____________________________________________________

___________________________________________________________________________________.

Plaintiff is unable to determine whether or not Defendant is on active military service.

(“Active military service” includes full-time duty in the military, including National Guard and the Reserves, and, for

members of the National Guard, service under a call to active service authorized by the President or the 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 penalties of perjury that the foregoing representations are true.

_________________________

______________________________________________

(date)

(Signature of Affiant)

Affidavit Of Debt Form

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