Ventura — Small Claims Itemization of Debt Attachment

Source: https://ventura.courts.ca.gov/system/files/vn187.pdf

VN187

Small Claims

Plaintiff Case Number

Page _________

SMALL CLAIMS ITEMIZATION OF DEBT (CCP 116.222) ATTACHMENT TO ITEM 3 OF SC-100 FORM

NOTE: Use of this form is not mandatory. You may submit this information in any written format (such as a written statement of account) as long as it contains all of the required information.

1. The original debt amount $ __________________

2. The following payments were credited to the debt:

   none payments as follows continued on attachment

   Date payment made Amount of Payment

3. The following fees and charges were added to the debt:

   nonenone fees and charges as follows continued on attachment

   Date added Amount of Fees/Charges

4. The following payments were credited against those fees and charges:

   nonenone paymentspayments asas followsfollows continued on attachment

   Date Payment Made Amount of Fees/Charges

   SMALL CLAIMS ITEMIZATION OF DEBT ATTACHMENT VN187 Rev 7/07

VN187

Small Claims
Plaintiff Case Number

Page _________

5. All other debits or charges to the account, and an explanation of the nature of those fees,
charges, debits are as follows:

none other fees, charges and debits as follows: continued on attachment

Date added Description of fees, charges and debits

6. All other credits to the debt, including from which source and the amount:

none other credits as follows: continued on attachment

Date of credits to account Source and amount of credits

Other

I declare, under penalty of perjury under California State law that the information above is true
and correct.

Date: ____________ ____________________________ ___________________________
Plaintiff’s printed name Plaintiff’s signature

VN187 Rev 7/07 SMALL CLAIMS ITEMIZATION OF DEBT ATTACHMENT