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Statement of Claim

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STATEMENT OF CLAIM
Date
Date
Date
For Office use ONLY :
Case Number: CI-
PLAINTIFF:
First Name
Last Name
Address1
City
State
Zip
-VS-
DEFENDANT:
First Name
Last Name
Address1
City
State
Zip
Please mark the appropriate action:
1. Suit on a Note
2. Suit on Account
3. Other
Is the Defendant an active duty member of the U.S. Armed Services?
1. Yes
2. No
The amount of the claim is:
Any Additional Charges: costs to date; and all future costs.
Plaintiff says the defendant is indebted to the plaintiff as follows:
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Statement of Claim

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