MAGISTRATE COURT OF ____________________ COUNTY, GEORGIA
DATE FILED ______________________ CASE NO. _____________________
___________________________________________
___________________________________________
STATEMENT OF CLAIM
___________________________________________
Plaintiff’s Name & Address
vs.
___________________________________________ _______________________________________________
___________________________________________ _______________________________________________
___________________________________________ _______________________________________________
Defendant’s Name & Address Defendant’s Name & Address (If two Defendants)
____________________________________________________________________________________________________________
DESIGNATION OF AGENT FOR BUSINESS ENTITY
Pursuant to O.C.G.A. § 15-10-43(i) and Uniform Magistrate Court Rule 31, this is to certify that
_____________________________________is a full-time employee or officer of the above-named corporation, limited liability
company, sole partnership, partnership, unincorporated association or other legal entity. I have been designated by said business to
represent it in the above-styled civil action. I have the authority to act of on its behalf and to bind it in the same manner as myself to
any and all matters related to this case.
Under penalty of perjury, signed this ____day of ___________, 20___.
Sworn to and subscribed before me
This __day of ___________, 20___.
__________________________________
Deputy Clerk/Notary Public
_____________________________________
Signature
_____________________________________
Printed Name
_____________________________________
Address
_____________________________________
City, State, Zip
