1. Defendant on or about ________________, 19_________, executed and delivered to Plaintiff a promissory note [in the following words and figures: (here set out the note verbatim)]; [a copy of which is hereto annexed as Exhibit A]; [whereby defendant promised to pay to plaintiff or order on __________________ 19_____, the sum of _________________ dollars with interest thereon at the rate of ___________ percent per annum] [and agreed to pay a reasonable attorney’s fee for collection].

2. Defendant owes to plaintiff [the amount of said note] [$______________ that is due on said note] and interest.

Wherefore plaintiff demands judgment against defendant for the sum of _____________ dollars, interest, attorney’s fee, and costs.

_______________________________

Attorney for Plaintiff

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Address