12.18
DOCKET NO.
PLAINTIFF DEFENDANT
COUNTY/COURT DIVISION
Trial Court of Massachusetts
AFFIDAVIT REGARDING DEBT
Mass. R. Civ. P. 8.1(c)
AFFIANT
SIGNED UNDER THE PENALTIES OF PERJURY
I. The affiant states that, to the best of the affiant's knowledge, the information provided below is accurate and
complete:
1. The name, position, and employer of the affiant:
2. The name of the current owner of the debt:
3. The name of the original creditor, including the name under which the original creditor did business with the defendant,
if different:
4. For debt arising from a credit card sponsored or co-sponsored by a retailer, the name of the sponsoring or co-sponsoring
retailer:
5. The last four digits of the account number(s) assigned by the original creditor:
6. The amount and date of the defendant's last payment, if any, or a representation by the affiant that no payment has been
made:
7. The date of charge-off:
8. The amount of the debt on the date of charge-off:
9. For the portion of the debt incurred after the date of charge-off, an itemization of the debt (broken down by principal,
interest, fees, or other charges) and the method of calculating such principal, interest, fees, or other charges:
10. A chronological listing of the names of all prior owners of the debt and the date of each transfer of ownership of the
debt, beginning with the original creditor:
II. The affiant has personally reviewed records sufficient to establish the information provided above.
X
THIS FORM IS REQUIRED IN ALL CASES SUBJECT TO MASS. R. CIV. P. 8.1
(if additional space is needed, please include an attachment)
DATE
