Affidavit Of Facts By Original Creditor Form
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1AFFIDAVIT OF FACTS BY ORIGINAL CREDITOR
(Original Creditor Actions)
The undersigned, being duly sworn, deposes and says:
❒
❒
1. I am a/an
of Plaintiff, and I have personal knowledge of and
[❒
employee
officer
member]
access to Plaintiffs books and records ("Business Records"), including electronic records, relating
to the account ("Account") of ______________________________ [name of Defendant]. The last
four digits of the Account number are __________. In my position, I have personal knowledge of
Plaintiff’s procedures for creating and maintaining its Business Records. Plaintiff’s Business
Records were made in the regular course of business and it was the regular course of such
business to make the Business Records. The records were made at or near the time of the events
recorded. Based on my review of Plaintiff’s Business Records, I have personal knowledge of the
facts set forth in this affidavit.
2. Plaintiff and Defendant entered into a credit agreement ("Agreement"). Defendant agreed to pay
Plaintiff for all goods, services and cash advances provided pursuant to the Agreement. The
amount of the last payment, if any, made by Defendant was $______________, made on
________________ [date]. Defendant is now in default and demand for payment has been made.
A true and correct copy of the Agreement is attached as an exhibit to this affidavit.
3. [Complete this paragraph if seeking judgment on an account stated cause of action.] I have
personal knowledge of Plaintiff’s procedures for generating and mailing account statements to
customers. It is the regular practice of Plaintiff’s business to provide periodic account statements
to its customers. On or about ________________ [date], Plaintiff sent one or more account
statements relating to the Account to Defendant stating the amount due as $______________.
The account statement(s) were mailed to Defendant's last known address and Plaintiff’s records
do not reflect that the statement(s) were returned by the post office or that the Defendant
objected to them. A true and correct copy of the final account statement(s) is attached as an
exhibit to this affidavit.
4. At this time, Defendant owes $______________ on the Account. This amount includes a charge-
off balance of $______________, post-charge-off interest of $______________, post-charge-off
fees and charges of $______________, less any post-charge-off credits or payments made by or
on behalf of the Defendant of $______________.
WHEREFORE, deponent demands judgment against Defendant for $______________, (plus interest
from ________________ [date], if applicable), together with the costs and disbursements of this
action.
The above statements are true and correct to the best of my personal knowledge.
Dated: ___________________
________________________________________
Signature
________________________________________
Name
Sworn to before me this _____ day
of ____________________,20____.
______________________________
Notary Public
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