Debt Affidavit Form

DEBT AFFIDAVIT FORM

I, Affiant Name: , make this affidavit on behalf of Creditor Name: in my capacity as Title/Capacity: , and declare under penalty of perjury the following facts within my personal knowledge or from records kept in the ordinary course of business.

RECITALS

WHEREAS, Creditor Name: extended credit to Debtor Name: pursuant to an account identified by Account Number: .

WHEREAS, the material facts concerning the account are as follows: Date of Last Payment: ; Date of Default/Charge-off: ; Original Creditor: .

WHEREAS, ownership and assignment history relevant to this claim is reflected in creditor records and supporting documentation as described below and attached hereto.

NOW, THEREFORE, Affiant states under oath and affirms the following:

1. STATEMENT OF AMOUNT DUE

As of the Date of This Affidavit: , the total balance due and owing on the Account referenced above is:

Principal Amount: $ Interest Accrued: $ Fees and Charges: $

Total Claimed Balance: $. This amount is calculated in accordance with the account ledger and is the amount the Creditor currently asserts is due and collectible.

2. ACCOUNT HISTORY AND ASSIGNMENTS

The account was originally opened with Original Creditor: . Ownership or servicing of the account has been transferred as follows (dates and transferees):

3. BASIS FOR CLAIM

Affiant states that the claim is based on the original contract, account statements, and records of payments and charge-offs maintained in the ordinary course of business. Affiant has reviewed the account file and certifies that the entries and balances reflected in those records are true and correct to the best of Affiant's knowledge, and that Affiant is authorized to make this affidavit on behalf of the Creditor.

4. ATTACHMENTS AND SUPPORTING DOCUMENTS

The following documents are attached to and incorporated into this affidavit as evidence supporting the claim (check all that apply and describe):

Statement of account or ledger
Assignment and bill of sale
Charge-off notice
Payment history and transaction records
Other (describe below)

5. REPRESENTATIONS AND CERTIFICATIONS

Affiant represents and certifies that: (a) Affiant has reviewed the account records and supporting documents; (b) the amounts stated in this affidavit are true, correct and complete as of the date of this affidavit; (c) the documents attached are genuine copies of business records maintained in the ordinary course of business; and (d) Affiant is competent to testify to the matters set forth herein.

Affiant further certifies that this affidavit is made in good faith and that the statements herein are made under penalty of perjury under the laws of the jurisdiction specified in the Governing Law clause below.

6. NOTICE INFORMATION

7. REMEDIES, LIMITATIONS AND USE OF AFFIDAVIT

This affidavit may be used by the Creditor or its successors or assigns in judicial or administrative proceedings to establish the existence, ownership, and amount of the indebtedness. Nothing in this affidavit limits the Debtor's rights to dispute the debt in a tribunal of competent jurisdiction. Affiant acknowledges that any false statement made herein knowingly and willfully may subject Affiant to penalties for perjury and other civil or criminal liabilities.

8. MISCELLANEOUS PROVISIONS

Governing Law: The validity, interpretation and enforcement of this affidavit shall be governed by the laws of the jurisdiction designated by the Creditor for governing disputes arising from the underlying account, without regard to conflict of law principles. Governing jurisdiction is acknowledged to be appropriate for any action to enforce or challenge the matters asserted herein.

Entire Agreement: This affidavit, together with its attachments, constitutes the entire written statement of facts, agreements and representations with respect to the account and supersedes any prior oral or written representations concerning the matters set forth herein.

Severability: If any provision of this affidavit is determined to be invalid or unenforceable, the remaining provisions shall remain in full force and effect and be construed so as to effectuate the parties' intent as nearly as possible.

Amendments and Waiver: No amendment or waiver of any provision of this affidavit will be effective unless in writing signed by an authorized representative of the Creditor. A waiver of any breach or right under this affidavit will not constitute a waiver of any other breach or right.

9. ACKNOWLEDGMENT

I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge and that I am authorized to execute this affidavit on behalf of the Creditor identified herein.

Sign Now