IN THE MAGISTRATE COURT OF
COUNTY, WEST VIRGINIA
Plaintiff v. Case No.
Defendant
AFFIDAVIT: REGARDING DEMAND FOR PAYMENT OF WORTHLESS CHECK
STATE OF WEST VIRGINIA COUNTY OF This day on his or her oath or affirmation says: 1. 2. I am the plaintiff in the above-styled action. That on (date), I delivered a written demand for payment of the check(s) by personal service or by certified mail or regular mail (if regular mail is selected complete number 3) with a notice of intent to file a lawsuit pursuant to W.Va. Code § 55-16-1 if payment is not received within 30 days. If service was achieved by regular mail, (check one) I have attached a post-marked certificate of mailing or I attest that on a written demand was mailed to the defendant at the following (date) address: Thirty days (30) have now passed, and I have not received full payment of the check debt. , TO-WIT, appeared before me, and
3.
4.
Plaintiff's Signature Taken, subscribed and sworn or affirmed before me this My Commission expires on day of . ,20
Notary Public/Magistrate Assistant/Magistrate Clerk
NOTICE: The intentional filing of a false affidavit may constitute a criminal violation [see e.g., W.Va. Code § 61-5-3
W. Va. Code § 55-16-1 SCA-M336NP / 5-02
Copy Distribution:
File Plaintiff Defendant