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Claim by Camille Blackbourn
Plaintiff Name: CV/1/ / / t ° 44 ) Address: QV.✓ 3 (q' 4i7 / ) it re 5 ©o ) Date of Birth* 4)' G? 19 ) ) Employer Identification Number ** Plaintiff Name: Address: DOB* DOB* IN THE IOWA DISTRICT COURT Employer Identification Number ** L117447 T>h £10o 1 Employer Identiicatioi• Number* * Defendant(s) Name: Address: Employer Identification Number ** Chew () ir by FOR DUBUQUE COUNTY ) ) ) vS. "� Defendant(s) Name: (/ - �l *P J �t / ) Address: 0 k/ -Ire+e .� t s ) ) DOB* ) ) ) ) ) ) ) ) SMALL CLAIMS ORIGINAL NOTICE (Action for Money Judgment) CASE 01311 SCSCO T7O ti C7' c D3 C C' = in Ai to 'v M C> N t >_ C: CJI p PLEASE NOTE: If assistance of auxiliary aids or services is required to participate in court due to a disability such as hearing impaired, call the Americans with Disabilities coordinator at (319)833 -3332. If you are in need of dual party telephone relay services, call Relay Iowa TTY at 1-800-735.2942. TO THE ABOVE NAMED DEFENDANT(S), YOU ARE HEREBY NOTIFIED that the Plaintiff(s) demand(s) from you the amount of 041 , 14711 7 - 06 based on r ��a - ('�lfi �s —td ,s c)" (State briefly the basis for the demand.) CIC( r , f C t - I b1.4 s . UNLESS YOU APPEAR by completing and filing the attached APPEARANCE AND ANSWER FORM with the Clerk of the District Court, Dubuque County Courthouse, 720 Centr 1 Avenue, PO Box 1220, Dubuque, Iowa 52004 -1220, within 20 days after service of this QRI 1NAL NOTICE upon4 ou, jut ment shall be rendered against you upon Plaintiff's claim together with interest aii caists. i f - - ) " IF i) DEW THE CLAIM AND APPEAR by filing the attached APPEARANCE AND ANSWER FORM within 20 days aft r service of this original notice upon you, you will then receive notification from the Clerk of District Court's office of the nd ti !pe for hear' g. Aso .S-1700f Sig �r (s �f Plaintiff(s) r laintiff's(s') � � 1 Attorney's Address 1A 7 z r cl i e. f Q 1 * Dates of birth must be furnished by partiesfrppearing as individuals as corporation, partnership or other entity.) (Such parties must also submit their social security numbers on the CONFIDENTIAL SOCIAL SECUITY NUMBER form, available from the Clerk of Court .) * *Employer identification numbers must be furnished by parties who are corporations, partnerships, or other legal entities. S:\D131Dubuque\small claims forms \scoriginalnot(9 - 10-08) 5