IN THE MAGISTRATE COURT OF GWINNETT COUNTY, STATE OF GEORGIA

__________________________________________________________________            Clerk, Gwinnett Magistrate Court, P.O. Box 246

                                                                                                                                                Lawrenceville, GA 30046-0246 (770- 822-8100, Ext. Civil Div.)

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                                                                                                                                                Civil Action No._____________________________________

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Plaintiff(s) Name, Address

Vs                                                                                                                                           STATEMENT OF CLAIM

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                                                                                                                                                          INFO & FORMS ON INTERNET, www.gwinnettcourts.com

__________________________________________________________________                  E-Mail: mag@gwinnettcounty.com,

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Defendant(s) Name, Address & Daytime Telephone #, if known; Or evening #.                          

[   ] Suit on Note     [   ] Suit on Account       [   ] Other ______________________________________________________________________

1.   The Court has jurisdiction over the defendant(s)   [   ] the Defendant(s) is a resident of Gwinnett County;   [   ] Other (please specify)

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2.   Plaintiff(s) claims the Defendant(s) is indebted to the Plaintiff(s) as follows: _________________________________________________________

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3.   That said claim is in the amount of $_______________________, principal $________________________ interest, plus ______________________

      costs to date, and all future costs of this suit.

State of Georgia, Gwinnett County:

________________________________________________________ being duly sworn on oath says the foregoing is a just and true statement the amount owing by defendant(s) to plaintiff(s), exclusive of all set-offs and just grounds of defense.

Sworn and subscribed before me this                                                                  _____________________________________________________________

                                                                                                                                      Plaintiff(s) or Agent

____________ day of _________________________________ 20_______        _____________________________________________________________                                                                                                                                             (If Agent-Title or Capacity)

_____________________________________________________________

Notary Public/Attesting Official                                                                               ____________________________________________________________

                                                                                                                                     Day Time Phone Number

      I request a civil trial: [   ] during normal business hours   –OR--  [   ]  6:30 p.m. Trial     ALL CONFLICTS WILL BE SET FOR 6:30 p.m. Trials                                                                                           

                                                                                                          NOTICE AND SUMMONS

TO: All Defendant(s)  You are hereby notified that the above named Plaintiff(s) has/have made a claim and is requesting judgment against you in the sum shown by the foregoing statement.  YOU ARE REQUIRED TO FILE or PRESENT AN ANSWER (answer forms can be obtained for the above listed web-site or clerk’s office) TO THIS CLAIM WITHIN 30 DAYS AFTER SERVICE OF THIS CLAIM UPON YOU.  IF YOU DO NOT ANSWER, JUDGMENT BY DEFAULT WILL BE ENTERED AGAINST YOU.  YOUR ANSWER MAY BE FILED IN WRITING OR MAY BE GIVEN ORALLY TO THE JUDGE.  If you choose to file your answer orally, it MUST BE IN OPEN COURT IN PERSON and within the 30 day period.  NO TELEPHONE ANSWERS ARE PERMITTED.  The court will hold a hearing on this claim at the Gwinnett Justice & Administration Center, 75 Langley Dr., Lawrenceville, GA [30045-6935], at a time to be scheduled after your answer is filed.  You may come to court with or without an attorney.  If you have witnesses, books, receipts, or other writings bearing on this claim, you should bring them to court at the time of your hearing.  If you want witnesses or documents subpoenaed, see a staff person in the Clerk’s office for assistance.  If you have a claim against the Plaintiff(s), you should notify the court by immediately filing a written answer and counterclaim.  If you admit to the Plaintiff(s)’ claim but need additional time to pay, you must come to the hearing in person and tell the court your financial circumstances.  Your answer must be RECEIVED by the clerk within 30 days of the date of service.  If you are uncertain whether your answer will timely arrive by mail, file your answer in person at the clerk’s office during normal business hours.

This ____________ day of ________________________, 20 ___           ___________________________________________________

                                                                                                                                                Magistrate or Deputy Clerk of Court

See Instructions on Reverse Side of this Document

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            I hereby certify that I [   ] have mailed; [   ] will mail immediately upon filing;

a copy of the following listed documents that I have filed with the clerk of court.

                                                                                                [   ]       Amended Statement of Claim;        [   ]            Amended Answer/Counterclaim;

                        [   ]       Other, ________________________________________________; to

            This _____ day of ____________, 200___.

                                                            _________________________________________

                                                            [   ]  Plaintiff [   ] Defendant

                                                            _________________________________________

                                                            Mailing address

                                                            _________________________________________

                                                            City, State & Zip       

                                                            ________________________________________

                                                            Phone # (Days)