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M AGISTRATE COURT OF ____________ ________ COUNTY, GEORGIA DATE FILED ______________________ ___________________________________________ ___________________________________________ CASE NO. _____________________ ___________________________________________ Plaintiff’s Name & Address vs. ___________________________________________ _______________________________________________ ___________________________________________ _______________________________________________ ______________________________ _____________ _______________________________________________ Defendant’s Name & Address Defendant’s Name & Address (If two Defendants) ____________________________________________________________________________________________________________ DISMISSAL OF CLAIM The Plaintiff(s) in the above styled action does ( do) hereby voluntarily dismiss the claim against the Defendant(s) [ ] with prejudice (case may not be re - filed). [ ] without prejudice (case may be re - filed within statute of li mitations). This ________ day of ____________________________, 20_____. ___________________________________________ Plaintiff(s) DISMISSAL OF COUNTERCLAIM The Defendant(s) in the above styled action does ( do) hereby voluntarily dism iss the claim against the Plaintiff(s) [ ] with prejudice (case may not be re - filed). [ ] without prejudice (case may be re-filed within statute of limitations or within 6 months from date of dismissal, whichever is longer.) This________ day of ____________________________, 20_______. ___________________________________________ Defendant(s) CERTIFICATE OF SERVICE I hereby certify that I have served a copy of this Dismissal upon the other party in the following manner: [ ] by hand delivering a copy to the other party; [ ] by mailin g a copy by first class mail to the address listed below: __________________________________________________________________________________ __________________________________________________________________________________ _______________________ ___________________________________________________________ This _____ day of ________________________, 20 ___. ______________________________________________ [ ] Plaintiff(s) [ ] Defendant(s)

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