Creditor's Statement of Claim

CREDITOR'S STATEMENT OF CLAIM

Creditor Name:   Creditor Address:

Debtor Name:   Debtor Address:

RECITALS

WHEREAS, Creditor is the lawful owner and holder of the account identified as Account No.: , arising from goods sold or services rendered to Debtor; and

WHEREAS, Debtor incurred charges and fees on the referenced account under a written agreement obligating Debtor to pay principal, interest, and collection costs; and

WHEREAS, despite presentment and demands for payment, Debtor has failed to pay the amounts due and remains in default as of .

NOW, THEREFORE, in consideration of the foregoing recitals and the mutual covenants contained herein, Creditor asserts the following Statement of Claim against Debtor.

1. DEFINITIONS

For the purposes of this Statement, the following terms have the meanings set forth: "Account" means the transactions, charges, credits, and balances associated with the account number identified above; "Claim Amount" means the total principal, interest, fees and costs claimed by Creditor as described below.

2. STATEMENT OF CLAIM

Creditor asserts that as of the date of this Statement, the sums justly due and owing from Debtor on the Account are as follows:

3. ACCOUNT LEDGER (SELECTED TRANSACTIONS)

The following entries reflect a representative ledger of transactions toward the Account. Additional detailed statements are attached as supporting documentation.

Date:   Description:   Amount:

Date:   Description:   Amount:

Date:   Description:   Amount:

4. INTEREST

Interest shall accrue on the unpaid principal at the rate of per annum from the date of default until paid in full. Post-judgment interest shall be calculated in accordance with applicable law at the rate of .

5. SUPPORTING DOCUMENTATION

The following documents are attached or will be provided in support of this Claim (check all that apply):

  Account statements covering the balance claimed

  Copy of underlying agreement or contract

  Written correspondence and demand letters

  Itemized ledger or billing history

6. DEMAND

Creditor hereby demands judgment against Debtor in the amount of the Total Amount Claimed set forth above, together with accrued interest, costs of collection, attorneys' fees to the extent permitted by contract or law, and such additional relief as the tribunal deems just and proper.

7. REMEDIES AND RIGHTS RESERVED

Creditor reserves all remedies provided by law and contract, including but not limited to the right to pursue collection, set-off, wage garnishment, liens, and to seek recovery of reasonable collection costs and attorneys' fees. No single exercise of a remedy shall preclude any other remedy.

8. NOTICES

All notices required or permitted under this Statement shall be in writing and delivered by personal delivery, certified mail, or courier to the addresses set forth at the beginning of this document or to such other address as a party designates in writing. Notice shall be effective upon receipt.

9. GOVERNING LAW; MISCELLANEOUS

Governing Law: This Statement shall be governed by and construed in accordance with the laws of the state identified for governing law: , without regard to choice-of-law principles.

Entire Agreement: This Statement, together with any attachments, constitutes the entire written statement of claim between the parties with respect to the matters described herein and supersedes all prior writings and understandings.

Severability: If any provision of this Statement is held to be invalid or unenforceable, the remaining provisions will remain in full force and effect.

Amendments and Waiver: No amendment, modification or waiver of any provision of this Statement shall be effective unless in writing and signed by the party against whom such amendment, modification or waiver is asserted.

10. CERTIFICATION

The undersigned certify under penalty of perjury under the laws of the governing jurisdiction that the information contained in this Statement of Claim is true and correct to the best of their knowledge and that the amounts claimed are justly due and owing.

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