COMPLAINT BASED ON AN ACTIONABLE DOCUMENT

(Caption and Title)

COMPLAINT

Plaintiff thru counsel, and unto this Honorable Court, respectfully alleges:

1. The Plaintiff and the Defendant are both of age and residents
of_________________________________ ;

2. On or about________________ , the defendant obtained a loan from the

plaintiff in the sum of ________________payable on _____________at______% interest
per annum;

3. Said loan, now overdue, is evidenced by a promissory note signed by the

defendant, copy of which is hereto attached as annex A and made an integral part of this
complaint;

4. Defendant has not paid said loan nor any part thereof, despite plaintiff’s
repeated demand for payment.

WHEREFORE, it is respectfully prayed that:

1. Judgment be rendered against the defendant in favor of the plaintiff for the sum
of__________________ with interest at _________ % until the full amount is paid;

2. Defendant be made to pay the costs of suit.

(Venue, date, signature)

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