Fill and Sign the Defendants Name Amp Address Form

M AGISTRATE COURT OF ____________________ COUNTY, GEORGIA DATE FILED ______________________ CASE NO. _____________________ ___________________________________________ ___________________________________________ ST ATEMENT OF CLAIM ___________________________________________ Plaintiff’s Name & Address vs. ___________ ________________________________ _______________________________________________ ___________________________________________ _______________________________________________ ___________________________________________ _______________________________________________ Defendant’s Name & Address Defendant’s Name & Address (If two Defendants) __________________ ___ ____ ___ ___ ____ ___ ____ ___ ___ ____ ___ ___ ____ ___ ___ ____ ___ ___ ____ ___ ____ ___ ___ ____ ___ __ ____ DESIGNATION OF AGENT FOR BUSINESS ENTITY Pursuant to O.C.G. A. § 15 - 1 0-43(i) and Uniform Magistrate Court Rule 31, this is to certify that _ __ __ __ __ __ __________________________ is a full-time employee or officer of the abo ve -named corporation, limited liability company, sole partnership, partnership, unincorporated association or other legal entity. I ha ve been designated by said business to represent it in the abo ve -styled civ il action. I ha ve the authority to act of on its behalf and to bind it in the same manner as myself to any and all matters related to this case. Under penalty of perjury, signed this ____day of ___________ , 20___. Sw orn to and subscribed before me This __day of ___________, 20___. _ ____________________________ _____ Deputy Clerk/Notary Public _____________________________________ Signature _____________________________________ Printed Name ____________________________________ _ Address _____________________________________ City, State, Zip