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STATE OF ____________________________ )
COUNTY OF __________________________ )

BEFORE ME, the undersigned authority, on this day personally appeared the undersigned affiant, who swore on oath that the following facts are true:

"1)My full name is _______________________________________.

"2) I am employed by ______________________________________________, the Plaintiff named in the petition to which this affidavit is attached and made a part hereof, and I have care, custody, and control of all records concerning the account of the Defendant in this cause.

"3) These records show that a balance of $______________, is due and payable by the Defendant

to _____________________________, Plaintiff.

"4) Defendant's account, marked as ('Exhibit A" and attached to Plaintiff's Original Petition, is within my personal knowledge just and true. The true amount of the account is due Plaintiff by Defendant, and all just and lawful onsets, payrnents, and credits have been allowed.

"5) Demand for payment of the just amount owing Plaintiff by Defendant has been made on Defendant more than thirty (30) days prior hereto and payment for the just amount owing has not been tendered.''

_________________________________________ ______________________                                                    Affiant                                                             Date

SWORN T0 AND SUBSCRIBED before me on ________________________, _______                                                                                                  Month Day Year

Notary Public

State of___________________________________

County of_________________________________

Commission expires:_________________________

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