CREDITORS AFFIDAVIT

I, of , the
undersigned, being of age, do of my own personal knowledge make the following statements
and declare them to be true.
1. That I am of , Plaintiff in
this action, and have custody of its book and records.
2. That according to said books and records, and my own personal knowledge, Defendant is
justly indebted to Plaintiff in the amount of $ without setoff or defense.
3. That despite repeated demand for payment, no payment has been received.
4. That there is no insurance coverage or other posted security from which to satisfy this
claim.
Signed under the pains and penalties of perjury this day of , (year).
STATE OF
}
COUNTY OF
On before me, , personally appeared
, personally known to me (or
proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same
in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument
the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Signature___________________________
Affiant _____Known _____Unknown
ID Produced________________________
(Seal)
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