Fill and Sign the To Any Authorized Officer You Are Hereby Commanded to Summon the Defendants Form

WARRANT IN DEBT (CIVIL CLAIM FOR MONEY ) Commonwealth of Virginia VA. CODE § 16.1-79 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General District Court CITY OR COUNTY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STREET ADDRESS OF COURT TO ANY AUTHORIZED OFFICER: You are hereby commanded to summon the Defendant(s). TO THE DEFENDANT(S): You are summoned to appear before this Court at the above address on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to answer the Plaintiff(s)’ civil claim (see below ) RETURN DATE AND TIME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________________________________________ DATE ISSUED [ ] CLERK [ ] DEPUTY CLERK [ ] MAGISTRATE CLAIM : Plaintiff(s) claim that Defendant(s) owe Plaintiff(s) a debt in the sum of $ . . . . . . . . . . . . . . . . . . net of any credits, with interest at . . . . . . . . % from date of . . . . . . . . . . . . . until paid, $ . . . . . . . . . . . . . . . . . . . costs and $ . . . . . . . . . . . . . . . . . . attorney’s fees with the basis of this claim being [ ] Open A cco unt [ ] Contr act [ ] N ote [ ] Other (EXPLAIN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOMESTEAD EXEMPTION WAIVED? [ ] YES [ ] NO [ ] cannot be demanded . . . . . . . . . . . . . . . . . . __________________________________________________________ DATE [ ] PLAINTIFF [ ] PLAINTIFF’S ATTORNEY [ ] PLAINTIFF’S EMPLOYEE/AGENT CASE DISPOSITION JUDGMENT against [ ] named Defendant(s) [ ] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . for $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . net of any credits, with interest at . . . . . . . . . . . . . % from date of . . . . . . . . . . . . . . . . . . . . . . . . . . until paid, $. . . . . . . . . . . . . . . costs and $ . . . . . . . . . . . . . . . . . . . . . attorney’s fees HOMESTEAD EXEMPTION WAIVED? [ ] YES [ ] NO [ ] CANNOT BE DEMANDED [ ] JUDGMENT FOR [ ] NAMED DEFENDANT(S) [ ] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] NON-SUIT [ ] DISMISSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Defendant(s) Present? [ ] YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] NO . . . . . . . . . . . . . . . . . . . . . . . ________________________________________________________ DATE JU DGE CASE NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAINTIFF(S) (LAST NAME, FIRST NAME, MIDDLE INITIAL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEFENDANT(S) (LAST NAME, FIRST NAME, MIDDLE INITIAL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WARRANT IN DEBT * * * TO DEFENDANT: You are not re quired to appear; however, if you fail to appear, judgment may be entered against you. See the additional notice on the reve rse about requesting a change of trial location. [ ] To dispute this claim, you must appear on the return date to try this case. [ ] To dispute this claim, you must appear on the return date for the judge to set another date for trial. Bill of Particulars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ORDERED DUE Grounds of Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ORDERED DUE ATTORNEY FOR PLAINTIFF(S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ATTORNEY FOR DEFENDANT(S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HEARING DATE AND TIME _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ JUDGMENT PAID OR SATISFIED PURSUANT TO ATTACHED NOTICE OF SATISFACTION. . . . . . . . . . . . . . . . . . . . . . DATE . . . . . . . . . . . . . . . . . . . . . CLERK DISABILITY ACCOMMODATIONS for loss of hearing, vision, mobility, etc., contact the court ahead of time. FO RM DC-4 12 ( PAGE ONE OF TWO ) 07/04 PDF RETURNS: Each defendant was served according to law, as indicated below, unless not found. NAME......................................................... ................................................................. ADDRESS .................................................... ................................................................. NAME .............................................................. ...................................................................... ADDRESS ......................................................... ...................................................................... NAME .............................................................. ...................................................................... ADDRESS ......................................................... ...................................................................... [ ] PERSONAL SERVICE Tel. No. .............................. [ ] PERSONAL SERVICE Tel. No. ............................... [ ] PERSONAL SERVICE Tel. No. .................................. Being unable to make personal service, a copy was delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above. _____________________________________________ _____________________________________________ [ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.) [ ] Served on Secretary of the Commonwealth Being unable to make personal service, a copy was delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above. _____________________________________________ _____________________________________________ [ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.) [ ] Served on Secretary of the Commonwealth Being unable to make personal service, a copy was delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above. _______________________________________________ _______________________________________________ [ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.) [ ] Served on Secretary of the Commonwealth [ ] NOT FOUND ____________________________ [ ] NOT FOUND ____________________________ [ ] NOT FOUND ________________________ SERVING OFFICER ...................... for_ __________________________ DATE SERVING OFFICER ..................... for _____________________________ DATE SERVING OFFICER ...................... for__ ______________________ DATE I certify that I mailed a copy of this document to the defendants named therein at the address shown therein on .................................... ______________________________ DATE [ ] Plaintiff [ ] Plaintiff's Atty. [ ] Plaintiff’s Agent OBJECTION TO VENUE: To the Defendant(s): If you believ e that Plaintiff(s) should have filed this suit in a different city or county, you may file a written request to have the case moved for trial to the general di strict court of that city or county. To do so, you must do the following: 1. Prepare a written request which cont ains (a) this court's name, (b) the case number and the "return date" as shown on the other side of this form in the right corner, (c) Plaintiff(s)' name(s) and Defendant(s)' name(s), (d) the phrase "I move to object to venue of this case in this court because" and state the reasons for your objection and also state in which city or county the case should be tried, and (e) your signature and mailing address. 2. File the written request in the clerk's office before the tr ial date (use the mail at your own risk) or give it to the judge when your case is called on the return date . Also send or deliver a copy to plaintiff. 3. If you mail this request to the court, yo u will be notified of the judge's decision. Fi. Fa. issu ed on ............................................................................ Interrogatories issued on: .............................................................. Garnishment i ssued on .................................................................. ........................................................................................................ FORM DC-412, DC-414, DC-428 (REVERSE) REVISED 07/04