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SMALL CLAIMS No. C-J4 In the Small Claims Court Precinct 4 Denton County Texas Plaintiff s vs. 816 N Highway 377 Roanoke Texas 76262 972-434-3910 Fax 972-434-3911 Defendant s State of Texas County of Denton STATEMENT OF Check one ORIGINAL CLAIM AMENDED CLAIM COUNTERCLAIM The above-named Plaintiff who can be notified at Address City State Zip Home and/or Cellular Phone Work Phone being duly sworn on his/her oath deposes and says that the above-named Defendant who can be served with citation at Registered Agent to Serve If Applicable Title is justly indebted to the Plaintiff in the sum of plus court costs for here state the nature of the claim in concise form and without technicality including all pertinent dates see additional page s attached and that there are no counterclaims existing in favor of the Defendant and against the Plaintiff except. Printed Name Agent for Plaintiff s Signature Subscribed and sworn to before me this Clerk of the Court or Notary Public day of. AFFIDAVIT SEC. 201 b Servicemembers Civil Relief Act Plaintiff/agent/attorney being duly sworn on oath under penalty of perjury fine and/or up to one year in jail deposes and says that defendant s check one Is not subject to the Servicemembers Civil Relief Act of 2003 or a dependent of a servicemember. Is on active military duty and/or is subject to the Servicemembers Civil Relief Act of 2003. Defendant has waived his/her rights under the Servicemembers Civil Relief Act of 2003. Servicemember status of defendant is unknown at this time. Agent s Attorney s Signature STATE OF TEXAS COUNTY OF DENTON. Printed Name Agent for Plaintiff s Signature Subscribed and sworn to before me this Clerk of the Court or Notary Public day of. AFFIDAVIT SEC. 201 b Servicemembers Civil Relief Act Plaintiff/agent/attorney being duly sworn on oath under penalty of perjury fine and/or up to one year in jail deposes and says that defendant s check one Is not subject to the Servicemembers Civil Relief Act of 2003 or a dependent of a servicemember. AFFIDAVIT SEC. 201 b Servicemembers Civil Relief Act Plaintiff/agent/attorney being duly sworn on oath under penalty of perjury fine and/or up to one year in jail deposes and says that defendant s check one Is not subject to the Servicemembers Civil Relief Act of 2003 or a dependent of a servicemember. Is on active military duty and/or is subject to the Servicemembers Civil Relief Act of 2003. Defendant has waived his/her rights under the Servicemembers Civil Relief Act of 2003. Is on active military duty and/or is subject to the Servicemembers Civil Relief Act of 2003. Defendant has waived his/her rights under the Servicemembers Civil Relief Act of 2003. Servicemember status of defendant is unknown at this time. Agent s Attorney s Signature STATE OF TEXAS COUNTY OF DENTON. Printed Name Agent for Plaintiff s Signature Subscribed and sworn to before me this Clerk of the Court or Notary Public day of. AFFIDAVIT SEC. 201 b Servicemembers Civil Relief Act Plaintiff/agent/attorney being duly sworn on oath under penalty of perjury fine and/or up to one year in jail deposes and says that defendant s check one Is not subject to the Servicemembers Civil Relief Act of 2003 or a dependent of a servicemember. Is on active military duty and/or is subject to the Servicemembers Civil Relief Act of 2003. Defendant has waived his/her rights under the Servicemembers Civil Relief Act of 2003.

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