jay219683Consumer Statement.pdf

jay219683Consumer Statement.pdf - For e-Filing only ~0...

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For e-Filing only THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH Court Name: Case Name: Case Number: (if known) STATEMENT OF CONSUMER DEBT In accordance with Small Claims Rule 4.1(D)(3), the undersigned submits this Statement: 1. Statement submitted by: Name: Address: City, State, Zip Code: Relationship to the plaintiff: Basis for this Statement: 2. Basic information for cases arising from the extension of consumer credit: Account number or account identifier (Caution: Redact this number to show only the last four digits.): Date of last payment, if any: Amount of last payment, if any: $ Debt principal amount: $ Interest, charges and fees calculated as set forth in Rule 4. 1 (D)(3)(d): 3. Additional information required for small claim actions arising from the extension of consumer credit in which the plaintiff is a person or entity other than the original creditor: By completing this section, the filer is stating that the plaintiff has a right to assert this small claim.
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