Fill and Sign the On Line Account Opening Form

IN THE CIRCUIT COURT OF_________ COUNTY, ____________ PLAINTIFF )       ) ) ) NO. V. ) ) NAME OF DEFENDANT )       ) AFFIDAVIT OF AMOUNT DUE ON OPEN ACCOUNT STATE OF ____________ COUNTY OF __________ PERSONALLY CAME AND APPEARED BEFORE the undersigned authority in and for said county and state, __________ who, being by me first duly sworn, stated upon his oath the following: 1. I am __________ of __________, __________(state). I am more than 21 years of age and suffer from no legal or mental disability. 2. I am the owner of __________, a sole proprietorship with its principal place of business in __________(city), __________ County, __________(state). I have personal knowledge of the facts set forth in this Affidavit. 3. Defendant in the above styled and numbered cause, __________, agreed and contracted to pay for materials and services rendered to Defendant on credit. Said __________ is justly indebted to __________ in the principal sum of $_____, which represents reasonable compensation for the services rendered, as evidenced by the statement of account and the invoices attached hereto and incorporated herein by reference. 4. The attached statement of account is true, just, accurate and correct as stated, no part of same has been paid, the same is currently due and owing from said __________, said account is not usurious, nor is it subject to any setoff, and said __________ has not paid and has failed and refused to pay said account. 5. Plaintiff has made written demand upon Defendant __________ to pay the amount owed as specified and itemized in the statement of account and the invoices attached hereto, but Defendant has failed or refused to pay the same within thirty (30) days. ______________ __________ SWORN TO AND SUBSCRIBED BEFORE ME on this the _______ day of ___________, _______. ______________ NOTARY PUBLIC My Commission Expires: ____________